JANUAKY 


MANUAL 


OF 


GTNECOLOGT 


BY 


D.  BERRY  HART,  M.D.,  F.R.C.P.E., 

LECTURER   ON   MIDWIFERY   AND   DISEASES   OF   WOMEN,    SCHOOL   OF    MEDICINE,    EDINBURGH  ;    LATE 

ASSISTANT   TO   THE    PROFESSOR   OF    MIDWIFERY,    UNIVERSITY   OF    EDINBURGH;    LATE 

PRESIDENT   OF   THE   ROYAL   MEDICAL  SOCIETY,    ETC.  \ 


A.  II.  B ARBOUR,  M.A.,  B.Sc.,  M.B., 

ASSISTANT   TO   THE   PEOFESSOR   OF   MIDWIFERY,    UNIVERSITY   OF   EDINBURGH  ',    LATE    PRESIDENT 
OF   THE   ROYAL   MEDICAL   SOCIETY 


VOLUME  I. 


WITH  EIGHT  PLATES  AND  ONE  HUNDRED  AND  NINETY-TWO   WOODCUTS 


NEW  YORK 

WILLIAM    WOOD     &    C  O  M  P  A  N  Y 

56  &  58  LAFAYETTE  PLACE 
1S83 


TROW*S 

PRINTING  AND  BOOKBINDING  COMPANY 

201-213  East  Twelfth  Street 

NEW  YORK 


TO 

OUR  FRIEND  AND  TEACHER, 

ALEXANDER  RUSSELL  SIMPSON,  M.D.,  F.R.S.E., 

PROFESSOR  OP  MIDWIFERY  AND  DISEASES  OF  WOMEN  AND  CHILDREN 
IN  THE  UNIVERSITY  OF  EDINBURGH. 


PREFACE. 


IN  writing  this  Manual  we  have  tried  to  keep  before  our  eyes  the 
great  principle  that  the  Anatomy,  Physiology  and  Pathology  of  the 
Pelvic  Organs  form  the  foundation  of  good  Clinical  work.  As  stu- 
dents \ve  felt  the  want  of  a  text-book  based  on  this  principle  and  em- 
bodying the  most  recent  views  from  the  various  literatures  instead 
of  giving  those  of  one  school.  This  want  we  have  endeavoured  to 
supply. 

Our  thanks  are  due  to  Professor  Simpson  for  his  kind  advice  in 
matters  of  difficulty  ;  and  specially  to  .Mr.  •!.  A.  Melville,  for  the  lit- 
erary revision  of  the  text  and  the  preparation  of  the  copious  Table 
of  Contents  and  Indexes.  We  have  in  all  cases  acknowledged  the 
source  of  every  illustration  not  specially  prepared  for  this  work. 

D.   P>.   HART. 

A.   II.   B ARBOUR. 

EDINBURGH. 


TABLE   OF  CONTENTS. 


JJort  1. 

ANATOMY,  PHYSIOLOGY,  AND   METHOD   OF  EXAMI- 
NATION OF  THE  FEMALE  PELVIC  ORGANS. 

SECTION  I. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  FEMALE  PELVIC 

ORGANS. 


CHAPTER  I. 

PAGE 

GENERAL  ANATOMY  OF  EXTERNAL  GENITALS  AND  CONTENTS  OF  PELVIS 2 

External  Genitals  as  observed  Clinically,  3 ;  The  Pelvic  Floor  and  Organs 
resting  on  it,  considered  as  a  whole,  7 ;  The  Pelvis  considered  in  detail : 
Musculature  of  the  Pelvic  Floor,  8 ;  The  Uterus  and  its  Annexa,  13 ; 
Fallopian  Tubes,  20 ;  Ovaries,  23 ;  The  Vagina,  25  ;  The  Bladder,  29  ; 
Rectum,  34  ;  Perineal  Body,  37  j  Peritoneum,  38 ;  Connective  Tissue  of 
Pelvis,  44. 

CHAPTER  II. 

THE  POSITION  OF  THE  UTERUS  AND  ITS  ANNEXA,  AND  THE  RELATION  OF 

THE  SUPERJACENT  VISCERA 51 

The  Normal  Form  and  Position  of  the  Uterus,  53 ;  The  Local  Divisions  of 
the  Pelvic  Floor  Peritoneum  as  viewed  through  the  Pelvic  Brim,  and  the 
Position  of  the  Uterine  Annexa,  56 ;  The  Physiological  Changes  in  the 
position  of  the  Uterus,  57 ;  The  Relation  of  the  Small  Intestine  to  the 
Pelvic  Floor  and  to  the  Uterus  with  its  Annexa,  59. 


CHAPTER  in. 

THE  STRUCTURAL  ANATOMY  OF  THE  FEMALE  PELVIC  FLOOR 60 

Public  Segment,  61 ;  Sacral  Segment,  61. 

PELVIC  FLOOR  PROJECTION.  .  65 


Vlll  CONTENTS. 

CHAPTER  IV. 

PAGE 

BLOOD-VESSELS  OP  THE  PELVIS 69 

Arterial  Supply:  to  Uterus,  Ovaries,  etc.,  69;  to  Perineal  Region,  70; 
Venous  Distribution,  70. 

LYMPHATICS  OF  THE  PELVIS 72 

Lymphatic  Glands,  72  ;  Lymphatic  Vessels :  of  External  Genitals,  72 ;  of 
Vagina  and  Cervix  Uteri,  73  ;  of  Uterus,  73. 

NEKVES  OP  THE  PELVIS 74 

Spinal,  74 ;  Sympathetic,  74. 

DEVELOPMENT  OP  PELVIC  ORGANS. 74 

CHAPTER  V. 

PHYSICS  OP  THE  ABDOMEN  AND  PELVIS,  WITH  SPECIAL  REFERENCE  TO  THE 

SEMIPRONE  AND  GENUPECTORAL  POSTURES 76 

The  effect  of  Intra-abdominal  Pressure  on  the  Female  Pelvic  Floor,  76  ;  The 
Results  brought  about  by  change  of  Posture,  especially  by  the  Genupectoral 
Posture,  78 ;  The  effect  on  Uterine  position  of  Digital  Pressure  in  the 
Vaginal  Fornices,  82  ;  Relation  of  Posture  to  Examination  and  Treatment, 
83. 

CHAPTER  VI. 

MENSTRUATION  AND  OVULATION 85 

Preliminary  Considerations,  85  ;  General  Phenomena  of  Menstruation,  86  ; 
Local  Phenomena,  86;  Ovulation,  87;  Corpus  Luteum,  87  ;  Source  of  Dis- 
charge, 88  ;  Changes  in  the  Uterine  Mucous  Membrane,  88. 


SECTION  H. 
PHYSICAL  EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 

CHAPTER  VII. 

ABDOMINAL  EXAMINATION  ;  VAGINAL  EXAMINATION  ;  THE  BIMANUAL  EXAMI- 
NATION WITH  ITS  VARIOUS  MODIFICATIONS 95 

External  Abdominal  Examination,  95  ;  Inspection  of  External  Genitals,  98 ; 
Vaginal  Examination,  99 ;  Bimanual  or  Abdomino- Vaginal  Examination, 
101 ;  Other  Methods  of  Abdominal  Examination,  105. 

CHAPTER  VIH. 
EXAMINATION  PER  RECTUM 106 

Simple  Rectal,  Abdomino-Rectal,  and  Abdomino-Recto-Vaginal,  106 ;  Simon's 
Method  of  passing  the  Hand  into  the  Rectum,  108. 


CONTENTS.  IX 


CHAPTER  IX. 

PAGE 

THE  VOLSELLA 110 

Description  of  Instrument,  110;  Methods  of  Use.  Ill  ;  Mechanism  of  Dis- 
placement it  causes,  112  ;  Uses  in  Diagnosis,  112  ;  Uses  in  Treatment,  113; 
Contra- indications,  114. 


CHAPTER  X. 

VAGINAL  SPECULA 115 

Spatula  Speculum — the  Sims,  115  ;  Tubular  Speculum — the  Fergusson,  118; 
Bivalve  Speculum— the  Neugebauer,  119;  Bivalve  Speculum — the  Cusco, 
121 ;  Uses  and  comparative  value  of  the  various  Specula,  121. 

CHAPTER  XI. 
THE  UTERINE  SOUND 123 

Nature,  122  ;  Preliminaries  to  its  use  ;  when  not  to  use  it,  123  ;  Method  of 
use,  124 ;  Employment  of  the  Sound  for  Diagnosis,  128 ;  Employment  of 
the  Sound  for  Treatment,  129  ;  Dangers  attending  its  use,  129  ;  Sound  com- 
bined with  Bimanual,  130 ;  Relation  of  Sound  to  Bimanual  and  Rectal  Ex- 
amination, 130. 

CHAPTER  XII. 

THE  SPONGE  TENT  AND  OTHER  UTERINE  DILATORS 132 

Dilatation  by  Sponge,  Tangle,  and  Tupelo  Tents  :  Material,  132 ;  Purposes 
for  which  used,  133 ;  Preliminaries  to  and  Method  of  Use,  135 ;  Dangers 
in  use  and  contra-indications,  137  ;  Dilatation  by  graduated  Hard  Rubber 
Dilators— Tait's,  Hank's,  137. 


CHAPTER  XIII. 

THE  CURETTE 139 

Varieties,  139 ;  Cases  in  which  the  Curette  is  useful,  140 ;  Method  of  Use, 
140  ;  Cautions  and  Dangers,  141. 

CHAPTER  XIV. 

KNIVES;  SCISSORS;  NEEDLES;  SUTURES;  ANTISEPTICS;  DOUCHES  AND  STB- 

INGES  ;  CAUTERY  ;  ANAESTHETICS 142 

Knives,  142;  Scissors,  142;  Needles,  143;  Sutures,  144 ;  Antiseptics,  144; 
Vaginal  Syringes  and  Douches,  145  ;  Cautery,  147  ;  Anaesthetics,  149 ;  Ac- 
tion of  Chloroform,  149 ;  Uses  of  Chloroform,  150  ;  Method  of  Adminis- 
tration, 151  ;  Dangers,  152. 


CONTENTS. 


flart  2. 
DISEASES  OF  THE  FEMALE  PELVIC  ORGANS. 

SECTION  HI. 
AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE. 

CHAPTER  XV. 

PAGE 

PELVIC  PERITONITIS 159 

Pathological  Anatomy  and  Varieties,  161 ;  Etiology,  161  ;  Symptoms  and  Phy- 
sical Signs,  163  ;  Differential  Diagnosis,  164 ;  Course  and  Results,  164 ; 
Prognosis,  164  ;  Treatment :  Prophylactic,  165 ;  General,  165 ;  Local,  168. 
PELVIC  CELLULITIS 169 

Pathological  Anatomy  and  Varieties,  169  ;  Etiology,  170 ;  Symptoms,  171 ; 
Physical  Signs,  171 ;  Differences  and  Differential  Diagnosis  between  Pelvic 
Peritonitis  and  Cellulitis,  172 ;  Course  and  Results,  173 ;  Prognosis,  174 ; 
Treatment,  174 

CHAPTER  XVI. 
PELVIC  H^MATOCELE 175 

Nature,  175  ;  Pathological  Anatomy,  176  ;  Etiology :  Sources  of  Hemorrhage 
and  Varieties,  178  ;  Symptoms,  180  ;  Physical  Signs,  180  ;  Diagnosis  and 
Differential  Diagnosis,  182 ;  Course  and  Results,  182 ;  Prognosis,  182  ; 
Treatment:  At  onset  of  Hemorrhage,  183;  After  Suppuration  has  oc- 
curred, 183. 

SECTION  IV. 
AFFECTIONS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES. 

CHAPTER  XVII. 

FALLOPIAN  TUBE  PAROVARIUM;  ROUND  LIGAMENT  ;  BROAD  LIGAMENT;  TUBO- 

OVARIAN  CYSTS 187 

Abnormalities,  188 ;  Stricture  of  the  Tubes,  188 ;  Patulous  Condition  of  the 
Tubes,  189  ;  Inflammatory  Conditions  of  the  Tubes,  Catarrhal  Salpingitis, 
188  ;  Hydrops  Tubas,  190;  Pyosalpinx,  191 ;  Hsematosalpinx,  191 :  New  For- 
mations, 191. 

PAROVARIUS!  t  191 

ROUND  LIGAMENT _  191 


CONTENTS.  XI 

PAGE 

HYDROCELE 191 

BROAD  LIGAMENT 192 

TUBO-OVARIAN  CYSTS 192 

CHAPTER  XVIII. 
MALFORMATIONS  OF  OVARY  ;  OVARITIS  AND  PERIOVARITIS 193 

Pathological  Anatomy,  194 ;  Etiology,  194 ;  Symptoms  and  Physical  Signs, 
195 ;  Differential  Diagnosis,  195  ;  Progress  and  Results,  195  ;  Treatment, 
195  ;  Periovaritis,  196. 

DISPLACEMENTS  OF  THE  OVARY— HERNIA 196 

Etiology,  196  ;  Diagnosis  and  Differential  Diagnosis,  197 ;  Treatment,  197. 
PROLAPSUS 197 

Pathological  Anatomy,  197;  Etiology,  198;  Symptoms,  198;  Physical  Signs, 
198 ;  Treatment,  198. 

CHAPTER  XTX. 
BATTEY'S  OPERATION 200 

History  of  Operation,  200 ;  Nomenclature,  200 ;  Nature  and  Aims  of  Opera- 
tion, 201 ;  Indications  for  Operation  and  its  Resnlts,;201 ;  Method  of  per- 
forming the  Operation,  203 ;  Vaginal  Method,  203 ;  Abdominal  Section, 
204 ;  General  Conclusions,  206. 

CHAPTER  XX. 
PATHOLOGY  OF  OVARIAN  TUMOURS 207 

The  Mode  of  Origin  of  Ovarian  Cysts,  208 ;  Varieties  of  Ovarian  Tumours, 
211  ;  Naked-eye  Anatomy,  211 ;  Microscopic  Anatomy,  212 ;  The  Nature 
of  Ovarian  Fluids  and  of  Parovarian  Fluid,  213 ;  Solid  Ovarian  Tumours : 
:  Non- Malignant,  215  ;  Malignant,  215. 

CHAPTER  XXI. 

DIAGNOSIS  OF  OVARIAN  TUMOURS 217 

When  Small,  aid  Pelvic  in  position,  217;  Lateral  to  Uterus,  217  ;  Posterior 
to  Uterus,  219  ;  When  large,  and  chiefly  Abdominal  in  position,  219 ;  Symp- 
toms, 219  ;  Physical  Signs,  220  ;  Differential  Diagnosis,  221 ;  Diagnosis  of 
Adhesions,  223  ;  Co  existence  of  Pregnancy  and  Ovarian  Tumour,  223. 

CHAPTER   XXII. 

OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS 224 

OVARIOTOMY 225 

Vaginal  Method,  225  ;  Abdominal  Method,  226 ;  Requisites,  226  ;  Prelimina- 
ries, 228;  The  Incision,  228  ;  Evacuation  of  Cyst,  229  ;  Drawing  out  of  the 


CONTENTS. 

PAGE 

Cyst  from  the  Abdomen,  229  ;  Separation  at  the  Pedicle,  230  ;  Treatment 
of  Adhesions  and  Bleeding,  232  ;  Toilette  of  the  Peritoneum,  233  ;  Closure 
of  Wound,  233;  Drainage,  233;  Dressing  of  the  Wound,  234;  After-Treat- 
ment :  Treatment  of  Complications,  234  ;  Relation  of  Listerism  to  Ovari- 
otomy, 234  ;  Ovariotomy  by  Enucleation,  235  ;  Ovariotomy  when  Pregnancy 
is  present,  235  ;  Contra-  indications  to  Ovariotomy,  236  ;  Course  and  Re- 
sults of  Ovarian  Tumours  when  left  alone,  236  ;  Adhesions,  236  ;  Torsion 
of  Pedicle,  236. 


SECTION  V. 

AFFECTIONS  OF  THE  UTERUS. 

CHAPTER  XXIII. 

MALFORMATIONS  OP  THE  UTERUS  ..........................................  241 

Pathology,  242  ;  Etiology  and  Classification,  246  ;  Symptoms,  247  ;  Diagnosis, 
250  ;  Prognosis,  251  ;  Treatment,  251. 

CHAPTER  XXIV. 

ATBESIA  OF  THE  CERVIX  UTERI  ...........................................  252 

Etiology  and  Pathology,  252. 

STENOSIS  OF  THE  CERVIX  ..................................................  253 

Pathology,  253  ;  Etiology,  254  ;  Symptoms,  254  ;  Diagnosis,  255  ;  Prognosis, 
255  ;  Treatment  :  Dilatation,  256  ;  Division,  257. 

CHAPTER  XXV. 

ATROPHY  OF  THE  CERVIX  AND  UTERUS  .....................................  261 

SUPERINVOLUTION  OF  THE  UTERUS  .........................................  262 

Pathology,  262  ;  Etiology,  262  ;  Symptoms,  264  ;  Diagnosis,  264  ;  Treatment, 
264. 

CHAPTER  XXVI. 

HYPERTROPHY  OF  THE  CERVIX  ;  AMPUTATION  ...............................  268 

Pathology,  268  ;  Etiology,  269  ;  Symptoms,  269  ;  Diagnosis,  269  ;  Treatment, 
270  ;  Amputation  with  Scissors  or  Knife,  270  ;  Amputation  with  Ecraseur 
or  Cautery,  275. 

HYPERTROPHY  OF  THE  CERVIX—  SUPRA-  VAGINAL  PORTION  ...................  275 

Treatment,  278. 

CHAPTER   XXVII. 

LACERATION  OF  THE  CERVIX  ...............................................  279 

Pathology,  280  ;  Etiology,  282  ;  Symptoms,  282  ;  Diagnosis,  283  ;  Treatment  : 
Emmet's  Operation,  285. 


CONTENTS.  Xlll 


CHAPTEE  XXVIII. 

PAOH 

CHRONIC  CERVICAL  CATARRH 288 

Pathology,  288  ;  Etiology,  293  ;  Symptoms,  294 ;  Physical  Signs,  294 ;  Diag- 
nosis and  Differential  Diagnosis,  295  ;  Prognosis,  296 ;  Treatment,  296. 


CHAPTER  XXIX. 
ENDOMETRITIS 800 

Pathology,  300  ;  Etiology,  304 ;  Symptoms  of  Acute  Endometritis,  305 ; 
Symptoms  of  Chronic  Endometritis,  305  ;  Physical  Signs  of  Acute  Endome- 
tritis, 307 ;  Physical  Signs  of  Chronic  Endometritis,  307 ;  Diagnosis,  Differ- 
ential Diagnosis,  308  ;  Prognosis,  308 ;  Treatment  of  Aqute  Endometritis, 
309  ;  Treatment  of  Chronic  Endometritis,  309. 


CLASSIFIED  LIST  OF  ILLUSTRATIONS 
IN  THIS  VOLUME, 


To  facilitate  study,  we  have  grouped  the  illustrations  under  the  following  heads : 


Anatomy — naked  eye. 
[Sectional  anatomy. 
Anatomy — microscopic. 
Pathology — naked  eye. 


Pathology — microscopic. 
Gynecological  examination. 
Instruments. 
Operations. 


AXATOMY— NAKED  EYE. 

LATE    I.   Surface  view  of  abdomen  and  thorax facin< 

"     III.  Distribution  of  ovarian,  uterine,  and  vaginal  arte- 
ries   

"  VIII.  Erosion  and  laceration  of  cervix. .  '' 


Page 


Fig.  P 

2G  Anterior   vacrinal  wall   and  multi- 


External  genitals 4 

External  genitals  in  section 5 

Hymen  of  virgin  with  vertical  slit.  7 

Hymen  of  virgin  with  oval  opening  7 

Crescentic  hymen 7 

Outlet  of  bony  pelvis 8 

Dissection  of  perineal  region 9    ol  Urethral  glands  of  Skene 

Diagram  of  perineal  muscles 9    '.}'•}  Course  of  the  ureters  .  .  . 

Muscles  of  clitoris  and  bulb. . .  10    ',}(>  The 


parous  cervix  

27  Diagram  of  vertical  mesial  section 

of  pelvis 

28  Horizontal  section  of  pelvic  floor 

at  pelvic  outlet 


GO 

G9 

95 

age 

26 


Oblique  coroual  section  through 
external  genitals 11 

Transverse  section  of  pelvis 12 

Levator  ani  and  coccygeus !•'> 

Virgin  uterus,  from  front  and  in 
section 1-5 

JIultiparous  uterus,  from  front  and 
in  section 

Diagram  of  divisions  of  cervix.  .  .  . 

17,  Is,  Sections  of  uterus  at  vari- 
ous levels Hi 

Fallopian  tube,  ovary,  ami  paro- 
varium 

Vagina  on  vertical  section 


rectum      inflated,     showing 
sphincters 

4s  Diagram  of  coronal  section  of  pel- 
vis   

49  Transverse  section  of  pelvis  in  line 

of  pyriform  muscle 

50  Schtilt/.e'.s   diagram   of   position  of 

uterus 

5'3  Contents  of   female   pelvis   viewed 
through  pelvic  brim 

54  Utr-rus    seen    through    brim,    with 

bladder  distended 

55  Diagram  of  position  of  uterus,  ac- 
21  cording  to  distention  of  bladder. 
25    57  Lines  of  cleavage  in  pelvic  lloor. .  . 


14 
16 

17 


XVI 


LIST    OF    ILLUSTRATIONS. 


Fig. 


Page 


59,  61,  Diagram  of  pelvic  floor  projec- 
tion  66,  67 

62  Venous  supply  of  uterus  and  va- 

gina      71 

63  Diagram  of  intra-abdommal  prea- 


77 


Fig. 


Pago 


64  Outline  of  figure  in  genupectoral 

posture • 78 

68,  69  Diagram  of  uterus  before  and 

after  menstruation 89 

154  Nulliparous  os  uteri 258 


155  Multiparous  os  uteri. 


259 


SECTIONAL  ANATOMY. 
PLATE  IL  Coronal  section  of  female  cadaver — frozen facing  p.  59 


Fig. 


Page 


34  Vertical   mesial   section,    showing 

Y-shape  of  bladder  —  frozen  .....     33 

35  Vertical  section  of  pelvis,  with  blad- 

der contracted  —  frozen  .........     34 

38  Vertical    mesial    section    showing 

peritoneum  —  frozen  ............     38 

39  Vertical  mesial  section,  with  blad- 

der contracted,  showing  perito- 
neum —frozen  .................     39 

40  Vertical  mesial  section,  with  ute- 

rus drawn  back,  showing  perito- 
neum —  spirit  hardened  .........     40 

41  Vertical  mesial  section  with  peri- 

toneum dipping  abnormally  deep 
—  frozen  ......................     41 

42  Vertical  mesial  section,  at  end  of 

pregnancy*—  frozen  .............     42 


Fig.  Page 

43  Vertical  mesial  section,  during  par- 

turition— frozen 43 

44  Vertical  mesial  section,  with  blad- 

der distended — frozen 44 

45  Lateral    sagittal    section  —  spirit 

hardened ; . . .     46 

46  Transverse  section  at  level  of  hip- 

joints—frozen 47 

47  Coronal  section  of  pelvis — frozen . .     48 

51  Vertical  mesial  section  with  blad- 

der disteiided 54 

52  Vertical  mesial  section  with  blad- 

der contracted — frozen 55 

56  Vertical  mesial  section,  during  par- 
turition— frozen 62 

65  Vertical  mesial  section  of  pelvis  in 

genupectoral  posture— frozen. . .     81 


ANATOMY— MICROSCOPIC. 


PLATE  VII.  Section  of  ovary  and  Wolffian  body  of  a  foetal 

lamb facing  p.  216 

"       "      Connective  tissue  sprouting  up  and  surrounding 

the  germ  epithelium "     p.  216 


Pig. 


Page 


19  Course  of  glands  of  mucous  mem- 

brane of  uterus 18 

20  Vertical  section   through  mucous 

membrane  of  uterus 19 

21  Vertical   section  through  mucous 

membrane  of  cervix 

23  Section  of  ovary  of  cat 


20 

23 

24  Section  of  human  ovary 24 


Fig. 


Page 


29  Section  of  posterior  wall  of  blad- 

der and  anterior  of  vagina 28 

30  Transverse  section  of  urethra 29 

32  Epithelial   cells  from  vesical  mu- 
cous membrane 81 

37  Perpendicular  section  through  end 

of  rectum 36 

70  Mucous   membrane  of   menstrua- 


ting uterus. , 


90 


PATHOLOGY— NAKED  EYE. 


Fig. 


101  Cervical  canal  dilated  by  a  poly- 


Page 

pus 135 

119  Uterus  retroverted  and  fixed  with 

adhesions. 169 


Page 


Fig. 

120  Retro-uterine    haematocele,   with 

pouch    of    Douglas    obliterat- 
ed    177 

121  Retro-  uterine   hsematocele,   with 


LIST    OF     ILLUSTRATIONS. 


XV11 


Fig.  Page    Fig.  Page 

pouch    of    Douglas    not    pre-           148  Stenosis  of  os  with  dilated  cervi- 
viously  obliterated 177  cal  canal 254 

122  Ante-  and  retro-uterine  blood  ef-  149  Normal  and  pinhole  os  in  specu- 

fusion 179  lum 255 

123  Free  blood  in  pouch  of  Douglas. .  181  158  Uterus  and  ovaries  from  a  case  of 

124  Hydrops  tubae 189  superinvolution 263 

137,  li>8  Rudimentary  uterus 242  160,  161  Hypertrophied   vaginal   por- 

1:59  Uterus  bipartifcus 243  tion  of  cervix 267,  268 

140  Uterus  unicornia 243  169  Hypertrophy  of  intermediate  por- 

141  Uterus  bicornis 244  tion  of  cervix 274 

142  Uterus  septus 245  170  Hypertrophy  of  supra-vaginal  por- 

143  Infantile  uterus 245  tion  of  cervix 274 

144  Primary  atrophy  of  uterus 246  171  Hypertrophy  of  whole  uterus  sec- 

145  Fo3tation  in  detached  horn  of  ute-  ondary  to  prolapsus 275 

rus 248    173  Single  laceration  of  cervix 278 

146  Uterus  septus,  puerperal 249    174  Multiple  or  stellate  laceration  of 

147  Conical  vaginal  portion 253  cervix 279 

PATHOLOGY- MICROSCOPIC. 

PLATES    VI.    }  Foulis  cells,  from  ascitic  fluid  in  malignant  (    facing  p.  211 

and   VIE.    j      tumor  of  ovary (         "     p.  216 

PLATE  VIII.  Section  of  cervix  with  simple  erosion "     p.  295 

Fig.  Page    Fig.  Page 

126  Cellular   bodies  —  the   source   of  180  Follicular  form  of  erosion 290 

ovarian  cysts. : 208    181  True  ulceration  of  the  cervix. . . .  291 

127  Diseased  blood-vessels  in  ovary  . .  209    186  Hypertrophied  glands  in  endome- 

128  Epithelial  tubes— the    source   of  tritis 301 

ovarian  cysts  210    187  Mucous  membrane  in  endometri- 

129  Papillas  of  ovarian  cyst  wall 212  tis  f  ungosa 302 

130  Colloid  degeneration  of   ovarian  188  Dilated  Wood-vessels  in  endome- 

stroma 212  tritis 303 

131  Cells  from  ovarian  fluid 215    189  Granulation    from    endometritis 

179  Papillary  form  of  erosion 289  composed  of  embryonic  tissue  .  303 

GYNECOLOGICAL  EXAMINATION. 

PLATE  IV.  Female  cadaver  in  semiprone  posture facing  p.  116 

"  V.  Female  cadaver  in  semiprone  posture,  with  Sims' 
speculum  passed  and  uterus  drawn  down  with 
volsella T "  p.  117 

Fig.  Page    Fig.  Page 

66  Anteversion  produced  by  digital  75  Right  hand  in  abdomino-recto-va- 

pressure 82  ginal  examination 107 

67  Revroversion  produced  by  digital  78  Uterus  drawn  down  by  volsella  . .   113 

pressure 83  84  Method  of  holding  Sims'  speculum  117 

71,  72  Right  hand  in  bimanual.  .101,  102  92  First  stage  of  passing  sound 124 

73  Left  hand  in  bimanual 103  93  Second  stage  of  passing  sound,  in 

74  Displacement  of  pelvic  floor  and  retroverted  uterus 125 

abdominal  wall  in  bimanual. ...  104      94  Proper  contrasted  with  improper 

method  of  turning  the  sound  . .   126 


XV111 


LIST    OF    ILLUSTRATIONS. 


Fig. 


95  Second  stage  of   passing    sound 

with  uterus  to  the  front  .......  126 

96  Sound  arrested  in  anteflexion.  .  .  .  127 


Pig.  Page 

97  Sound  combined  with  bimanual . .   131 

102  Introduction  of  tangle  tents 136 

132  Area  of  dulness  in  ovarian  tumor 

and  ascites 223 


INSTRUMENTS. 


Fig.  FaKe 

58  Hand  holding  pessary 65 

60  Callipers    for    measuring    pelvic 

floor  projection. ..." 67 

76  A.  R.  Simpson's  volsella HI 

77  Hart's  volsella 112 

79  Sims'  tenaculum 114 

80,  81  Sims'  speculum 116 

82  Bozeman's  speculum 116 

83  Battey's  speculum 116 

85  Fergusson's  speculum 118 

86,  87  Neugebauer's  speculum 119 

88  Barnes'  crescent  speculum 120 

89  Cusco's  speculum -. 120 

90  Sir  J.  Y.  Simpson's  sound 123 

91  A.  R.  Simpson's  sound 123 

98  Laminaria  tents  before  and  after 

expansion 133 

99  Tupelo  tents  before  and  after  ex- 

pansion    134 

100  Tupelo  tent  expanded 134 

103  Tait's  dilators 137 

104  Hanks'  dilators 138 

105  Recamier's  curette 139 

106  Simon's  scoop , 140 


Fig. 

107  Thomas'  curette,  modified  by  A. 

R.  Simpson  .................. 

108  Sims'  curette  .................. 

109  Bozeman's  scissors  .............. 

110  Kuchenmeiater's  scissors  ........ 

111  Hart's  scissors  .................. 

112  Emmet's  needles.  .  ,  ............. 

113  Needle-holder  .................. 

114  fiigginson's  syringe  ........  ----- 

115  Vaginal  douche  ................. 

116  Paquelin's  cautery  .............. 

117  Cones  for  cautery  .............. 

118  Chloroform  drop-cork  ............ 

125  Munde's    pessary    for    prolapsed 

ovary  ........................ 

133  Spencer  Well's  trocar  ........... 

134  Ordinary  trocar  ................ 

135  Nelaton's  forceps  ............... 

136  Spencer  Wells'  clamp  ............ 

150  Schultze's  dilator.'  ............. 

151  Marion  Sims'  dilator  ............ 

152  Sir  J.  Y.  Simpson's  metrotome.  . 
157  Glass  plug  for  cervical  canal  ..... 

159  Galvanic  intra-uterine  stem  ...... 

168  Rake  for  removing  sutures  ...... 


140 
140 
142 
143 
143 
144 
144 
145 
146 
147 
148 
151 

199 
229 
229 
230 
230 
256 
257 
257 
260 
265 
273 


OPERATIONS. 


Fig.  Page 

153  Incision  made  by  metrotome  ....  258 
15B  Bilateral  division  of  cervix  with 

Kuchenmeister's  scissors 259 

162  Sims'  method  of  passing  the  sut- 

ures after  amputation  of  csrvix  269 

163  Marckwald's  method  of  splitting 

and  stitching  the  cervix  in  am- 
putation   269 

164  A.  R.  Simpson's  method  of  ampu- 

tating the  cervix 271 

165,  166  Introduction  of  sutures  in 

amputation  of  cervix 271 

167  Hegar's  method  of  passing  the 

sutures 272 

172  Amputation  of  hypertrophied  cer- 
vix in  prolapsus  uteri 276 

175  Emmet's  operation — denuded  sur- 
face.. .  285 


Fig.  Pftge 

176  Denuded  surface  as  made  by  Em- 

met  285 

177  Emmet's  operation — introduction 

of  sutures 286 

178  Emmet's  operation — tying  of  sut- 

ures  286 

182  Forceps  dressed  with  cotton  wad- 

ding for  applications  to  cervical 
canal 297 

183  Barnes'  speculum  for  introducing 

vaginal  tampons 298 

184,  185  Schroeder's  excision  of  cer- 
vical mucous  membrane 299 

190  Sound  dressed  with  wadding  for 

intra-uterine  applications 310 

191  Curetting  of  uterus 311 

192  Sir  J.   Y.   Simpson's  porte-caus- 

tique 321 


SECTION  I, 

ANATOMY  AND  PHYSIOLOGY  OF  THE  FEMALE 
PELVIC  ORGANS. 

IN  order  to  give  a  comprehensive  idea  of  the  Anatomy  and  Physiology  of 
the  Female  Pelvic  Organs,  it  will  be  advisable  to  consider  it  in  the  follow- 
ing manner : 

CHAPTER  I.  (1.)  The  External  Genitals  as  observed  clinically.  (2.)  The 
Pelvic  floor  and  organs  resting  on  it  considered  as  a  whole.  (3.)  The  Pel- 
vis considered  in  detail  as  follows : — Musculature  of  Pelvic  Floor  ;  Uterus, 
Fallopian  Tubes,  and  Ovaries  ;  Vagina  ;  Bladder ;  Rectum  and  Perineal 
Body  ;  Peritoneum  and  Connective  Tissue. 

CHAPTER  II.  The  position  of  the  Uterus  and  its  annexa,  and  the  Vis- 
cera superjacent  to  the  Pelvic  Organs. 

CHAPTER  HL  The  Structural  Anatomy  of  the  Pelvic  Floor  ;  Pelvic 
Floor  Projection. 

CHAPTER  IV.  The  Blood-vessels,  Lymphatics,  and  Nerves  of  the  Pelvis. 
Development  of  Pelvic  Organs. 

CHAPTER  V.  Physics  of  the  Abdomen  and  Pelvis  with  special  reference 
to  the  Semiprone  and  Genupectoral  Postures. 

CHAPTER  VI.  Ovulation  and  Menstruation. 


CHAPTER  I. 

1JTERATTJBE. 

EXTERNAL  GENITALS.  Budin — Recherches  sur  1'hymen  et  1' orifice  vaginal :  Paris, 
1881.  MatJiews  Duncan — Papers  on  the  Female  Perineum  :  Churchill,  London, 
1880.  F.  P.  Foster — A  Cont'ribution  to  the  Topographical  Anatomy  of  the  Uterus 
and  its  Surroundings:  Am.  J.  of  Obst.,  Vol.  XIII.,  p.  30.  Garrigues — The  Ob- 
stetric Treatment  of  the  Perineum  :  Am.  J.  of  Obst.,  Vol.  XIII.,  p.  231.  Henle 
— Handbuch  der  Eingeweidelehre  des  Menschen  :  Braunschweig,  1 866. 

MUSCLES  OP  PELVIC  FLOOR.  Cunningham — The  Dissector's  Guide  ;  Abdomen  :  Mac- 
lachlan  &  Stewart,  Edinburgh,  1880.  Henle— op.  cit.  Luschka — Die  Musculatur 
am  Boden  des  weiblichen  Beckens  :  Wien,  1861.  Savage — Female  Pelvic  Organs, 
2d  Edition  :  London,  1870.  Turner — An  Introduction  to  Human  Anatomy :  A. 
&  C.  Black. 

UTERUS,  AND  ANNEXA  ;  VAGINA.  Barnes — The  Diseases  of  Women  :  London,  1878. 
BreisTcy — Die  Krankheiten  der  Vagina :  Billroth's  Handbuch,  Stuttgart,  1879. 
Cnivetthier — Traite  d'Anatomie  Descriptive :  Paris,  1871.  Engelmann — The  Mu- 
cous Membrane  of  the  Uterus:  Am.  J.  of  Obstetrics,  Vol.  VIII.,  p.  30.  Farre — 
The  Uterus  and  its  Appendages  :  Todd's  Cyclopaedia,  Vol.  V.  Hart — Structural 
Anatomy  of  Female  Pelvic  Floor  :  Maclachlan  &  Stewart,  1880.  Henle — op.  cit. 
Hennig — Der  Katarrh  der  inneren  weiblichen  Geschlechtstheile:  Leipzig,  1862. 
Munde — Prolapse  of  the  Ovaries  :  American  Gynecological  Transactions,  Vol.  IV. , 
1879.  Rainey — On  the  Structure  and  Use  of  the  Ligainentum  Rotundum  Uteri : 
Lond.  Phil.  Tr.,  1880,  p.  515.  Euge  and  Veit—Zur  Pathologic  der  Vaginal  Por- 
tion :  Stuttgart,  1878.  Sajrpey — Traite  d'Anatomie  Descriptive  :  Paris,  1873. 
Schrader — Handbuch  der  Krankheiten  der  weiblichen  Geschlechtsorgane  :  Leip- 
zig, 1879.  Taylor— American  Journal  of  Medical  Science,  Vol.  LXXX.,  p.  126. 
Turner — op.  cit. 

BLADDER.  H.  J.  Garrigues — Remarks  on  Gastro-Elytrotomy :  Am.  Gynecol.  Tr., 
Vol.  III.,  p.  212.  Skene— Diseases  of  the  Bladder  and  Urethra:  New  York,  1870. 
Skene'—  The  Anatomy  and  Pathology  of  Two  Important  Glands  in  the  Female 
Urethra:  Am.  J.  of  Obstetrics,  Vol.  XIII.  Winckel — Die  Krankheiten  der  weib- 
lichen Harnrohre  und  Blase  :  Billroth's  Handbuch,  Stuttgart,  1877. 

RECTUM.  Braune — Topoyraphisch  anatomischer  Atlas,  Zweite  Auflage :  Leipzig, 
Veit&Co.,  1872.  C/iadwick—The  Function  of  the  Anal  Sphincters  so-called: 
Am.  Gyn.  Tr.,  Vol.  II.,  p.  43.  Pirogoff—  Anatome  Topographica,  sectionibus 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS.  3 

per  corpus  humanum  congelatum  :  Petropoli,  1859.  Ruedinger — Topographisch- 
Chirurgische  Anatomie  des  Menschen :  Vierte  Abtheilung. 

PERINEAL  BODY.  Hart,  Herile,  Savage,  op.  cit.  T.  G.  Thomas — The  Female  Peri- 
neum; its  Anatomy,  Physiology  and  Pathology:  Am.  J.  of  Obstetrics,  Vol. 
XIII.,  p.  312. 

PERITONEUM  AND  CELLULAR  TISSUE.  Bandl — Die  Krankheiten  der  Tuben,  der 
Ligamente,  uud  des  Beckenperitonaums  :  Stuttgart,  1879.  Barnes — St.  George's 
Hospital  Reports,  Vol.  VII.,  p.  57.  Freund — Anatomische  Lehrmittel  zur  Gyna- 
kologie  :  Beitrage  zur  Geburtshulfe  und  Gynakologie.  Herausgegeben  von  der 
Gesellschaft  f iir  Geburtshulfe  in  Berlin.  IV.  Band,  1  Heft.  S.  58.  Guerin — Sur 
la  Structure  des  Ligaments  larges  :  Comptes  Rendus,  1879,  1364.  Le  Bee—  Con- 
tribution a  1'etude  des  ligaments  larges  (au  point  de  vue  de  1'anatomie  et  de  la 
pathologic) :  Gaz.  Hebd.,  15  Avril,  1881.  De  Sln'ty— Gynecologie  :  Paris,  1880. 
Spiegelberg— Remarks  upon  Exudations  in  the  Neighborhood  of  the  Female  Genital 
Canals  :  German  Clinical  Lectures  (New  Syd.  Soc.  Tr.),  p.  169.  Braune,  Cunning- 
ham, Hart,  Pirogoff,  op.  cit. 


(1.)  EXTERNAL  GENITALS  AS  OBSERVED  CLINICALLY. 

UNDER  the  term  external  genitals  are  comprised  the  structures  known  as 
Labia  Majora,  Fourchette,  Labia  Minora,  Clitoris  with  its  prepuce,  Vesti- 
bule, and  Fossa  Navicularis.  For  clinical  convenience  the  urethral  orifice 
and  hymen  also  are  described  with  these ;  although  the  urethral  orifice 
belongs  to  the  urinary  system,  and  the  hymen  separates  anatomically  the 
external  genitals  (vulva)  from  the  vagina. 

The  Labia  Majora  (Fig.  1,  a)  are  two  thick  folds  of  hair-clad  skin,  run- 
ning parallel  to  the  anteroposterior  diameter  of  the  pelvic  outlet,  extepd- 
ing  from  the  symphysis  pubis  backwards  between  the  thighs,  and  meeting 
each  other  posteriorly  in  the  middle  line  about  2.7  cm.  (1  inch)  in  front 
of  the  anus.  Each  labium  has  an  outer  and  inner  surface,  and  consists  of 
a  thick  fold  of  skin  enclosing  a  quantity  of  fat,  blood-vessels,  and  dartos. 
Superiorly,  where  they  are  best  developed,  they  form  by  their  junction — 
anterior  commissure — the  structure  known  as  the  mons  veneris  (vide 
Plate  I. )  ;  while  posteriorly,  they  are  a  mere  fold  of  skin  known  as  the 
Fourchette  or  posterior  commissure.  The  fat  and  connective  tissue  are 
therefore  almost  entirely  wanting  at  the  fourchette,  which  is  not  a  distinct 
structure  but  is  simply  the  posterior  junction  of  the  thinned- out  labia 
majora.  Both  labia  are,  in  the  adult,  covered  with  crisp  hair  which  is 
most  abundant  over  the  mons  veneris  and  outer  surface,  but  very  much 
less  on  the  inner. 


4  MANUAL    OF    GYNECOLOGY. 

The  Labia  Minora  (Fig.  1,  &)  are  two  small  oblique  folds  of  skin,  one 
on  the  inner  surface  of  each  labium  majus.  Posteriorly  they  blend  insen- 
sibly with  the  labium  majus  at  about  its  middle,  while  anteriorly  they 
converge  and  each  divides  into  two  small  branches,  an  upper  and  a  lower. 
The  upper  branches  meet  to  form  the  prepuce  of  the  clitoris  (Fig.  1,  c), 
while  the  lower  in  a  similar  way  form  its  suspensory  ligament.  As  a  rule 


Fro, 1 

External  genitals  of  virgin,  with  diaphragmatic  hymen.  The  labia  majora  and  minora  are  drawn 
apart,  and  the  prepuce  drawn  back,  a,  labium  majus  ;  6,  labium  minus  ;  c,  praeputium  clitoridis  ;  d,  glans 
clitoridis ;  «,  vestibule  just  above  urethral  orifice  ;  /,  mons  veneris  ("/i). 

the  labia  minora  do  not,  in  the  adult,  project  beyond  the  labia  majora. 
Sebaceous  glands  are  present  on  both  labia. 

The  Clitoris,  covered  by  its  prepuce,  lies  in  the  middle  line  and  at  the 
apex  of  the  smooth  piece  of  mucous  membrane  known  as  the  vestibule. 
Only  that  part  analogous  to  the  glans  penis  is  seen  (Fig.  1,  d).  The 
clitoris  proper  consists  of  two  crura  which  arise  from  the  rami  of  the 
ischium  and  pubis  and  unite  separately  to  form  the  body  of  the  clitoris, 
which  lies  beneath  the  mucous  membrane.  The  glans  clitoridis  is  not 


ANATOMY    OF  'THE    FEMALE    PELVIC    ORGANS. 


0 


directly  continuous  with  the  body,  but  joins  it  through  the-  pars  inter- 
media of  the  bulb  (i-ide  putt,  p.  10). 

The  Vct-libule  (Fig.  1,  c)  is  ;i  triangular  smooth  mucous  surface, 
bounded  superiorly  by  the  clitoris,  laterally  by  the  labia  minora,  and  in- 
feriorlv  by  the  upper  margin  of  the  vaginal  orifice.  In  the  middle  line  at 
its  base  the  dimple  of  the  urethral  orifice  can  be  distinctly  felt  2-2.5  cm. 
(1  inch)  in  front  of  fourchette.  Small  depressions  and  mucous  glands 
open  on  its  surface. 

The  Vaijinal  Orijice  lies  in  the  middle  line  between  the  base  of  the 
vestibule  and  the  fossa  navicularis.  Its  orifice  is  guarded  by  the  hymen, 
a  thin  fold  of  mucous  membrane  enclosing  some  connective  tissue,  blood- 
vessels, and  nerves  (,?;.  The  hymen  may  be  crescentic  in  shape,  attached 


XV 


Vertical  mesial  section  of  external  genitals  (Hcnlcl.      <i.  :um?  :  ';.  perinea!  body  :  c.  vagina  ;  d,  tmthr.i 


e.  labium  minus ; /,  prepuce  of  clitoris ;  0,  fossa  navicularis,  with  hymen  in  front  and  fourchette  bch.ml 


to  the  posterior  margin  of  the  vaginal  orifice,  and  with  free  edge  toward 
the  base  of  the  vestibule  (Figs.  2  and  5)  ;  or  diaphragmatic,  attached  all 
around  the  vaginal  orifice,  but  with  a  small  hole  (Figs.  1  and  4),  or  ver- 
tical slit  (Fig.  3)  in  it.  Sometimes  it  is  not  so  perforated,  constituting  a 
pathological  condition. 

/'(>•>•>•'£  Xtii:(<-//J'iri.<. — Normally,  the  inner  aspect  of  the  fonrchette  is  in 
contact  with  the  outer  and  lower  surface  of  the  hymen.  ^  lien  the 
fourchette  is  pulled  down  bv  the  finger,  a  boat-shaped  cavity  is  made 
the  fossa  navieularts.  Its  posterior  boundary  is,  therefore,  the  inner 
aspect  of  the  fourchette  :  its  anterior,  is  the  posterior  aspect  oi'  the  hymen. 
These  two  are  in  contact  unless  artificially  separated.  The  ducts  of  the 
ISartholinian  glands  open  into  the  fossa  by  small  pin-hole  apertures 
(Fig.  2). 


6  MANUAL    OF    GYNECOLOGY. 

From  behind  forwards,  in  the  female  ano-vulvar  region  there  lie  in  the 
.  middle  line  the  following  structures : — 
(1.)  Anus. 

(2.)  Skin  over  base  of  Permeal  Body. 
(3.)  Fourchette. 
(4.)  Fossa  Navicularis. 

(5.)  Vaginal  orifice,  with  Hymen  or  its  remains. 
(6.)  Urethral  orifice. 
(7.)  Vestibule. 

(8. )  Clitoris  with  its  prepuce. 
Laterally  we  have  the  labia  majora  and  minora. 

The  following  points  should  be  carefully  noted.  In  the  nude  erect 
female  only  the  mons  veneris  is  seen  (vide  Plate  I.).  The  well-devel- 
oped labia  majora  have  their  inner  surfaces  always  in  contact  and  are 
only  slightly  separated  by  the  widest  divergence  of  the  knees.  The 
labia  minora  are  always  in  contact  and  require  to  be  artificially  separated 
in  order  to  see  their  inner  surfaces.  The  fossa  navicularis  only  exists 
when  artificially  opened  up.  Therefore,  to  see  the  external  genitals  fully, 
the  labia  must  be  separated  and  the  prepuce  drawn  back. 

A  line  running  as  follows  separates  mucous  membrane  from  skin. 
Starting  from  the  base  of  the  inner  aspect  of  the  right  labium  minus,  it 
passes  down  beside  the  base  of  the  outer  aspect  of  the  hymen,  up  along 
the  base  of  the  inner  aspect  of  the  left  labium  minus,  in  beneath  the 
prepuce  of  the  clitoris,  and  down  to  where  it  first  started  from. 

The  vulvar  slit  is  vertical,  and  lies  in  the  middle  line  between  the 
labia  majora  and  minora. 

The  vaginal  orifice  is  transverse,  only  exists  when  artificially  made,  and 
is  anatomically  defined  by  the  hymen  which  separates  the  external  genitals 
from  the  internal  genitals.  The  sharp  line  between  skin  and  mucous 
membrane  can  be  distinctly  seen  on  the  living  woman.  The  labia  minora 
are  skin,  thin  and  fine,  and  not  mucous  membrane  as  often  alleged. 
The  following  measurements  by  Foster  are  useful  for  reference  : — 

,  Tip  of  Coccyx  Anus 

to  anus.         to  fourchette. 

Average  distance  in  nulliparse,     .     .     4.5  cm.  2.7  cm. 

"  multipart,     .     .     4.7  cm.  2.5  cm. 

Meatus  urinarius,  2-2.5  cm.  from  fourchette,  in  nulliparse  ;   2-3.1  cm.,  in 
women  who  have  borne  children. 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS.  7 

The  virginal  vaginal  orifice  should  have  the  appearances  shown  at  Figs. 
1,  3,  4,  and  5,  and  the  free  edge  of  the  hymen  should  be  intact. 

In  a  healthy  woman  who  has  experienced  complete  coitus,  the  hymen 
is  torn  or  often  only  stretched.  It  admits  twp  fingers  without  pain.  In 


Fisr.  3,  ^is.  4. 

Hymen  of  virgin  with  vertical  slit.  (V,)    Hymen  with  oval  opening.  (Vi) 


Crescentio  hymen.  (•/,) 


a  woman  who  has  borne  full-time  children,  the  vaginal  orifice  is  always 
torn  though  the  fourchette  and  all  behind  it  may  be  intact.  The  remains 
of  the  hymen  are  known  as  the  carunculse  myrtiformes.  In  addition,  the 
passage  of  the  child's  head  may  cause  tears  of  the  posterior  vaginal  wall, 
perineal  body,  or  even  anterior  wall  of  rectum. 


(2.)    THE  PELVIC  FLOOR  AND  .ORGANS  RESTING  ON  IT  CONSIDERED  AS 

A  WHOLE. 

The  outlet  of  the  bony  female  pelvis  is  filled  in  by  what  is  generally 
described  as  the  "  soft  parts."  This  term,  however,  should  not  be  em- 
ployed, as  it  is  misleading,  especially  in  scientific  obstetrics.  It  is  better 
named  the  pelvic  floor  or  pelvic  diaphragm. 

The  pelvic  floor  is  a  thick  fleshy  elastic  layer,  dovetailed  in  all  round 
to  the  bony  pelvic  outlet  (Fig.  6).  It  may  be  considered  as  an  irregularly- 
edged  segment  of  a  hollow  sphere,  with  an  outer  skin  aspect  and  an  inner 
peritoneal  one.  On  the  outer  skin  aspect  lie  the  external  genitals  already 
described.  On  the  inner  peritoneal  surface,  we  have  the  organ  known  as 
the  uterus,  and  its  appendages,  the  Fallopian  tubes  and  ovaries.  The 
vagina  runs  at  an  angle  of  60°  to  the  horizon  from  the  vaginal  orifice  up- 
wards to  the  mouth  of  the  womb,  as  a  transverse  slit  in  the  pelvic  dia- 
phragm. In  front  of  the  vagina  lies  the  bladder,  while  behind  it  the 


8 


MANUAL    OF    GYNECOLOGY. 


rectum  is  placed  ;  these  structures,  along  with  muscles,  connective  tissue, 
blood-vessels,  nerves,  and  lymphatics,  making  up  the  pelvic  diaphragm. 
Figure  1  shows,  accordingly,  the  pelvic  floor  seen  from  its  convex, 


Fig,  6. 

Bony  pelvic  outlet,  with  transverse  line  snowing  rectal  and  urethral  triangles  (D.  J.  Cunningham).  (J) 

skin  aspect ;  Fig.  53  gives  it  and  the  organs  resting  on  it  as  viewed  from 
its  concave,  peritoneal  side  ;  while  Fig.  34  displays  it  as  seen  in  vertical 
sagittal  section. 


(3.)  THE  PELVIS  CONSIDERED  IN  DETAIL. 

MUSCULATUKE   OF   THE   PELVIC    FLOOB. 

If  a  female  cadaver  be  placed  in  the  Lithotomy  posture  and  a  trans- 
verse line  drawn  just  in  front  of  the  ischial  tuberosities,  the  perineal 
region  will  be  divided  into  a  posterior  rectal  triangle  and  an  anterior 
urethral  one  (Fig.  6).  The  former  contains  the  anus,  the  latter  the  exter- 
nal genitals.  By  suitable  incisions  the  skin  and  superficial  fascia,  fat,  &c., 
can  be  removed  around  the  anus,  and  the  ischiorectal  fossa  defined.  This 
is  a  small  pyramidal  cavity  on  each  side  of  the  rectum,  bounded  externally 
by  the  obturator  internus  muscle,  internally  by  the  levator  ani.  Its  apex 
is  formed  by  the  junction  of  these  muscles,  while  its  base  is  partially 
closed  in  by  the  transversus  perinei  and  the  edge  of  the  gluteus  maximus 
muscle  (Fig.  7).  If  the  skin,  superficial  fascia,  and  anterior  layer  of  the 
triangular  ligament  be  now  removed  from  the  urethral  triangle,  the  follow- 
ing muscles,  &c.,  will  be  exposed  (Fig.  7). 

Perineal  Muscles. — On  each  side  of  the  vaginal  orifice  three  muscles 


ANATOMY  OF  THE  FEMALE  PELVIC  OKGANS. 


9 


lie,  viz.,  the  bulbo-cavernosus  (Fig.  8,  b  c),  erector  clitoridis  or  ischio-caver- 
uosus  (Fig.  8,  e  c),  and  transversus  perinei  (Fig.  8,  t  p). 

The  Bulbo  cavernosi  consist  of  two  muscular  slips,  one  on  e'ach  side  of 
the  vaginal  orifice,  which  spring  behind  from  the  perinea!  body  and  pass 
round  the  vaginal  orifice,  partly  covering  the  bulb  and  the  vagina  (Fig.  7, 
c).  The  anterior  end  of  each  slip  splits  into  three  portions,  which  end  as 
follows : — one  passes  to  the  under  surface  of  the  corpus  cavernosum  of  the 
clitoris,  a  second  goes  to  the  posterior  surface  of  the  bulb,  and  a  third 


Fig.  7. 

FIG.  7.— Dissection  of  perineal  region  (Savage),  a,  is  just  above  transversns  perinei ;  6,  base  of  peri- 
neal  body :  c,  bulbo-cavernosus ;  d,  lies  on  levator  ani  and  in  ischiorectal  fossa  ;  «,  erector  clitoridis ;  /,  bulb 
of  vagina;  g,  bartholinian  gland  ;  h,  vestibule  \j,  glans  clitoridis.  (J£) 

blends  with  the  mucous  membrane  between  the  clitoris  and  urethral 
orifice  (Henle,  v.  Fig.  9). 

The  Erector  Clitoridis  arises  from  the  inside  of  the  ischial  tuberosity, 
and  becomes  inserted  into  back  and  sides  of  the  cms  clitoridis  (Fig. 
9,  e). 

The  Transversus  Perinei  arises  from  the  ramus  of  the  ischium  and 
passes  to  the  perineal  body.  It  is  difficult  to  define  practically  in  dissec- 
tion (Fig.  7,  a). 

Now  that  these  muscles  are  defined,  we  are  in  a  position  to  localize 
more  important  structures. 

The  Bulbi  Vagince  (corpora  cavernosa  urethrse)  are   small   masses   of 


10 


MANUAL    OF    GYNECOLOGY. 


erectile  tissue  about  the  size  of  a  bean,  lying  one  on  each  side  of  the 
vaginal  orifice  and  partly  under  cover  of  the  bulbo-cavernosus  muscle. 
Each  rests  posteriorly  on  the  triangular  ligament,  internally  on  the  mu- 
cous membrane  of  the  vagina  ;  while,  as  already  said,  they  are  partly  cov- 
ered superiorly  by  the  bulbo-cavernosus  muscle.  Anteriorly  each  blends 
with  its  fellow,  and  this  pars  intermedia  becomes  continuous  with  the 
clitoris  (Fig.  7,/). 

The  Bartholinian  Glands  He  one  on  each  side  of  the  vaginal  orifice,  close 


Eig,9. 

a,  fiymphysis  pubis,  showing  muscles  in  connection  with  clitoris  and  bulb.  The  clitoris,  c,c",  is  cut 
across  near  its  point,  and  thrown  down  with  the  vestibulary  mucous  membrane  (Henle).  e,  erector  cli- 
toiidis ;  /,  bulbo-cavernosus  with  its  three  insertions ;  d,  venous  branch  to  dorsal  vein  of  clitoris,  ('/i) 

to  the  posterior  end  of  the  bulb  and  behind  the  anterior  layer  of  the  trian- 
gular ligament  (Figs.  7,  g,  and  10,  e).  Each  has  a  long  duct  opening  into 
the  fossa  navicularis. 

Between  the  lower  one-third  of  the  posterior  wall  of  the  vagina  and 
the  anterior  wall  of  the  rectum  is  an  angular  interspace  (Fig.  2,  6)  filled 
up  by  the  structure  known  as  the  perineal  body.  This  will  be  more  fully 
described  afterwards.  At  the  present  stage  of  the  dissection  only  its  base 
is  seen,  with  the  following  muscles  taking  origin  from  or  having  an  inser- 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGAX3. 


11 


tion  into  it, — -sphincter  ani,  transversus  perinei,  bulbo-cavernosus,  levator 
aui  (Fig.  7). 

Between  the  layers  of  the  triangular  ligament  lie  the  urethra,  a  por- 
tion of  the  vagina,  compressor  urethra;,  dorsal  vein  of  the  clitoris,  internal 
pudic  vessels  and  nerves,  the  artery  to  bulb,  dorsal  nerve  of  clitoris,  and 
Bartholinian  glands  (Cunningham). 

The  dissection  of  the  urethra!  triangle  has  now  been  considered  until 
the  bladder  has  been  exposed  as  it  lies  behind  the  pubis  from  which  it  is 
separated  by  a  considerable  amount  of  loose  fatty  tissue.  In  order  to 
complete  the  consideration,  Ave  have  now  to  take  up  the  muscles  not  yet 
described,  viz.,  the  levator  ani  and  coccygeus. 

The  pelvic  floor  must  now  be  looked  at  from  its  internal  concave  or 


peritoneal  aspect.  If  the  peritoneum  and  connective  tissue  beneath  it, 
with  the  nerves  and  blood-vessels,  be  removed  on  one  side  of  the  pelvis, 
say  the  right,  the  two  muscles  known  as  the  coccygeus  and  levator  ani 
will  be  exposed.  These  spring  from  the  middle  of  the  inner  side;  of  the 
true  pelvis,  and,  blending  partly  directly  and  partly  indirectly  with  one 
another,  form  what  may  be  termed  the  diaphragmatic  muscles  of  tin; 
pelvic  floor.  If  looked  at  through  the  pelvic  brim,  they  are  seen  to 
form  on  both  sides  a  concave  arrangement  analogous  to  the  thoracic,  dia- 
phragm (Fig.  11). 

The  Cncf'i/r/t'ii*  springs  from  the  spine  of  the  ischium  and  is  inserted 
into  the  side  of  the  lower  part  of  the  sacrum  and  side  and  front  of  coccyx. 
There  are  two  coccygei,  one  on  each  side  (Figs.  11  and  1'2). 


12 


MANUAL    OF    GYNECOLOQY. 


The  Levator  Ani  has  an  extensive  origin.  It  springs  in  front  from  the 
back  of  the  pubis,  from  the  pelvic  fascia  (white  line)  and  the  spine  of  the 
ischium.  From  this  the  muscle  sweeps  downwards  and  inwards  to  become 
attached  in  the  middle  line  from  before  backwards  as  follows, — to  the 


Kg/ 11. 

Transverse  section  of  pelvis  from  above  (Savage).  (%)   a,  sacrum ;  b,  urethra ;  c,  vagina  ;  d,  rectnm ; 
e,  levaCor  ani ;  /,  coccygeus ;  g,  obturator  internus. 

vagina,  the  rectum,  its  fellow  of  the  opposite  side,  and  finally  to  the  tip  of 
the  coccyx  (Fig.  12). 

Luschka's  monograph  may  be  consulted  for  a  more  minute  account. 

We  have  now  to  take  up  the  consideration  of  the  generative  organs. 
It  is  difficult  to  describe  these  without  alluding  to  structures  not  fully 
considered  until  further  on.  The  student  may,  therefore,  not  entirely 
grasp  some  of  the  points  until  the  whole  anatomy  of  the  organs  has  been 
mastered. 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


13 


Pfe.  12, 

Levator  ani  and  coccygens  seen  from  without,  after  removal  of  part  of  hip-bone  nnd  clearing  out  of 
ischiorectal  fossa  (Luschka).    a,  fibres  of  levator  ani  on  vagina  ;  6,  anus,  with  sphincter.  (>£) 


THE  UTERUS  AND  ITS  ANNEXA. 


The  Uterus  is  a  triangular  body,  with  a  truncated  apex  downward, 
placed  between  the  bladder  and  rectum,  and  with  the  appearance  seen 
at  Figs.  13,  A,  and  14,  B.  In  describing  it  we  take  up  its  external  appear- 
ance, its  nature  on  section,  and  its  structure  and  relations. 


Fig.  13. 

A,  virgin  uterus  (front  view)  (Sappey).  The  appendages  and  vagina  are  cut  away.  a.  cervix  (vaginal 
portion);  ft,  isthmus;  c,  body;  a,  6,  cervix  proper.  B,  The  same,  in  vertical  mesial  section,  a  is  anterior 
surface,  and  lies  just  above  where  peritoneum  passes  on  to  bladder.  C.  The  same,  with  cavity  exposed  by 
coronal  section,  e,  os  externum ;  d,  oa  internum ;  /,  uterine  opening  of  Fallopian  tube.  (]/i) 

On  external  examination  we  find  the  parts  known  as  the  body  (Fig.  13, 
A,  c)  and  neck  (Fig.  13,  A,  a,  b).     Keeping  in  mind  the  description  of  a 


14 


MANUAL    OF    GYNECOLOGY. 


triangle,  we  see  the  neck  occupying  the  apex  and  the  uterine  orifices  of 
the  Fallopian  tubes  at  the  two  other  angles.  Between  the  Fallopian 
tubes  lies  the  fundus  uteri.  The  anterior  surface  of  the  uterus  is  almost 
straight ;  the  posterior,  convex  at  its  upper  part,  as  is  well  seen  in  Fig.  13, 
B.  Where  the  body  passes  into  the  cervix  there  is  a  slight  depression 
noticed  on  the  posterior  surface.  This  corresponds  to  the  isthmus. 

On  making  a  vertical  mesial  section,  we  observe  that  the  uterus  is  a 
hollow  organ  possessing  a  cavity  with  the  anterior  and  posterior  walls  in 
apposition  (Fig.  13,  B).  In  order  to  see  the  cavity  it  is  advisable  to  look 
at  the  uterus  in  coronal  section,  i.e.,  a  section  which,  passing  through  the 


Pig.  14. 
A.  Multiparous  utertis  in  coronal  section  to  show  cavity.    B.  Multiparous  uterus  from  front  (Sappey).  (!/i) 

cavity,  divides  the  uterus  into  an  anterior  and  posterior  half,  as  shown  in 
Fig.  13,  C,  Fig.  14,  A.  This  latter  section  enables  us  more  fully  to  under- 
stand the  division  of  the  uterus  into  body  proper  and  cervix,  and  the 
division  of  the  uterine  cavity  into  cavity  of  the  body  proper  and  cervical 
cavity. 

Cavity  of  Body. — This  is  a  triangular  slit  in  the  uterus  with  the  apex 
downwards,  and  with  anterior  and  posterior  walls.  At  each  angle  there  is 
an  opening,  viz.,  at  the  lower  angle  we  have  the  os  internum  opening  into 
the  cervical  canal  (Fig.  13,  G,  d),  and  at  the  upper  angle  of  the  uterine 
openings  of  the  Fallopian  tubes  (Fig.  13,  C,f).  The  lining  of  the  cavity 
is  known  as  its  mucous  membrane. 

Cavity  of  Cervical  Canal — This  is  spindle-shaped  or  conical  (Fig.  13, 


ANATOMY  OF  THE  FEMALE  PELVIC  OKGAXS.        15 

B,  C),  and  lias  two  openings,  \'r/..,  os  intornum  alcove  and  os  externum 
below.  The  former  opens  into  the  uterine  cavity,  the  latter  into  the  vagina. 
17ie  Cervix  is  divided  into  two  portions,  the  vaginal  and  the  supra- 
vaginal  portion.  The  vaginal  portion  is  within  the  vagina,  and  appears  as 
a  conical  mass  of  the  size  and  shape  seen  at  Fig.  13,  A,  a.  The  os  ex- 
ternum is  in  virgins  a  mere  dimple,  and  feels  to  the  examining  finger  like 
the  tip  of  the  nose.  In  women  who  have  borne  children  it  is  transverse 
(Fig.  14,  P>)  and  in  most  cases  has  its  lips  fissured  more  or  less  deeply, 
and  the  mucous  membrane  of  the  cervical  canal  partially  everted.  The 
supra-vaginal  portion  is  continuous  with  the  body  through  the  isthmus. 

The  length  of  the  whole  unimpregnated  uterus  is,  speaking  generally, 
about  3  inches  ;  the  length  of  the  cavity  of  cervix  and  body  about  2.V 
inches. 

Virgin.  Xullipara;.        Multiparse. 

Length  of  uterus,       .         .     2.35  in.         2.50  in.         2.70  in. 
Width,       .         .         .         .     1.50  "  1.55  "  1.70  " 

Thickness,          .         .         .     0.85  "  0.90  "  1.00  " 

Saiyyey. 

Vertical  diameter  of  cavity,      1.80  "  2.44  in. 

Transverse    "  "     .     O.GO  "  1.24  " 

('•'On  Cadavera.")  Jt'i<:k<.'t. 

Length  of  entire  organ  in  young  women,  .          .     5-G     cm. 
Do.  body  of  uterus,         .          .          .      3-3.5   "' 

Do.  cervix,      .....     2-3       " 

Do.  vaginal  portion  of  cervix,  .   .55- .0    " 

ffcnnif/. 
Capacity  of  uterus  in  nulliparie  =  2-3  c.cm.  ;  in  multipar.i'  3-5  c.cni. 

's'  '1  Y  "'.'/• 

Various  authors  divide  the  cervix  uteri  more  minutely  as  follows. 
They  consider  it  as  made  up  of— 

a.  an  infravaginal  portion  ; 

b.  an  intermediate  portion  ; 

f.  a  supravaginal  portion.  (Fig.  15.      -SWijv^v/cr.) 

Dr.  I.  E.  Taylor  of  New  York  speaks  of— 

1.  The  firm  and  true  muscular  element  belonging  to  the  body  of  the 
uterus  solely,  clearly,  and  distinctly  ; 

2.  The  fibro-serous  element  existing  between  where  the  true  muscular 


16 


MANUAL    OF    GYNECOLOGY. 


structure  terminates,  and  the  cervix  uteri,  the  isthmus  or  intermediate 
part  begins ; 

3.  The  glandular  structure — the  cervix  proper. 


Fig,  'Ilk 


Diagram  of  nterns  to  show  divisions  of  cervix  (Schroeder).     a,  infravaginal  portion  ;  6,  intermediate 
portion  ;  c,  supravaginal  portion  ;  SI,  bladder ;  P,  peritoneum.     The  dotted  line  shows  peritoneum. 

These  two  views  are  of  importance  in  relation  to  the  causation  of  pro- 
lapsus uteri. 

Transverse  sections  of  the  uterus  at  different  levels  are  of  different 


Diagram  of  section  of  uterus  through  centre  of  cervical  canal  (Farre).  (>/!> 

shapes  (Figs.  16,  17,  and  18).     A  consideration  of  what  has  been  already 
said  will  make  this  clear. 


Fig,  17v 

Transverse  section  through  centre  of  cavity  (Farre).  ('/i) 

Recently  the  question  of  the  boundary  between  the  canal  of  the  cervix 
and  uterus  proper  has  been  raised  afresh  by  Bandl  and  others  in  reference 


ATST ATOMY    OF   THE    FEMALE    PELVIC    ORGANS.  17 

to  pregnancy  and  parturition.  Its  discussion  here,  would,  however,  bring 
in  too  much  extraneous  matter,  and  is  therefore  omitted,  more  especially 
as  the  whole  question  is  still  sub  lite. 

Structure  of  the  Uterus. — If  the  uterus  be  viewed  in  vertical  mesial 
section  it  will  be  seen  to  be  made  up  of  three  distinct  elements,  viz.,  peri- 
toneum, unstriped  muscular  fibre,  and  mucous  membrane  (Fig.  13,  B). 
The  peritoneum  covers,  partially,  its  external  surface  ;  the  mucous  mem- 
brane lines  the  cavity  of  the  body  and  cervix  ;  while  the  muscular  fibre, 
by  far  the  largest  constituent,  forms  the  tissue  lying  between  these. 

The  Peritoneum  of  the  Uterus  clothes  its  posterior  surface  entirely 
(except  the  vaginal  and  middle  portions  of  the  cervix)  but  only  dips  down 
on  the  front  surface  as  far  as  the  isthmus,  at  which  level  it  is  reflected  on 
to  the  bladder  (Fig.  13,  B,  a).  At  the  sides  of  the  uterus  the  peritoneum 


Fig.  18. 

Transverse  section  of  uterus  above  Fallopian  tubes  (Farre).  ( >/i) 

on  the  anterior  and  posterior  surfaces  runs  out  to  the  wall  of  the  pelvis, 
thus  forming  the  important  structures  known  as  the  broad  ligaments. 

The  Ligaments  of  the  uterus  are — 
Broad  ligaments  ; 
Round  ligaments  ; 
Utero-sacral  and  TJtero-vesical. 

The  broad  ligaments  are  described  under  the  peritoneum.    (See  p.  41). 

The  round  ligaments  are  two  in  number.  According  to  Bainey,  each 
springs  by  three  fasciculi  of  tendinous  fibres — the  inner  from  the  tendons 
of  the  internal  oblique  and  transversalis,  the  middle  from  the  superior 
column  of  the  external  abdominal  ring  near  its  upper  part,  and  the  outer 
fasciculus  from  just  above  Gimbernat's  ligament.  These  unite  into  a 
rounded  cord  which  crosses  in  front  of  the  deep  epigastric  artery  and 
passes  between  the  layers  of  the  broad  ligament  backwards,  downwards, 
and  inwards  to  the  anterior  and  superior  part  of  the  uterus.  Striped  and 

unstriped  muscle,  blood-vessels,  &c.,  are  found  in  each. 
2 


18 


MANUAL    OF    GYNECOLOGY. 


The  utero-sacral  ligaments  are  peritoneal  folds,  two  in  number,  enclos- 
ing connective  tissue  and  unstriped  muscular  fibre,  passing  from  the 
lower,  lateral  part  of  the  body  of  the  uterus  outwards  and  backwards  to 
the  second  sacral  vertebra.  They  are  known  as  the  folds  of  Douglas,  and 
form  part  of  the  upper,  lateral  boundaries  of  the  pouch  of  Douglas.  They 
are  of  the  highest  importance  practically.  The  peritoneum,  as  it  passes 
between  uterus  and  bladder,  constitutes  the  utero-vesical  ligaments. 

The  Musculature  of  the  Unimpregnated  Uterus  is  of  little  importance  in 
Gynecology,  and  needs  only  a  passing  notice.  Three  coats  are  described  : 
a  thin  subperitoneal  coat  passing  into  the  round  ligaments,  broad  liga- 
ments, utero-sacral  and  utero-vesical  ligaments ;  a  middle  coat ;  and  an 
inner  concentric  and  very  abundant  layer  which  surrounds  the  Fallopian 
tubes,  os  externum,  and  os  internum.  The  student  should  not  forget 


Pig.  19. 

Diagram  of  course  of  glands  of  mucous  membrane  of  uterus  (Engelmann).    (4%) 

that  the  arrangement  of  the  muscular  fibres  is  of  the  highest  importance 
in  practical  obstetrics. 

The  Mucous  Membrane  of  the  cavity  of  the  body  of  the  uterus  is  a  thin 
reddish-gray  layer,  about  1  cm.  (.04  inch)  thick  in  the  unimpregnated  but 
fully  developed  organ.  It  is  set  on  the  inner  aspect  of  the  muscular  layer 
of  the  uterus  without  the  intervention  of  any  submucous  layer,  is  made 
up  of  ciliated  columnar  epithelium  on  a  basis  of  connective  tissue  and  has 
numerous  glands — the  utricular  glands.  On  section  and  microscopic 
examination,  the  glands,  lined  by  the  ciliated  epithelium,  can  be  seen 
coursing  down  obliquely  from  the  free  surface  and  ending  at  the  muscular 
fibre.  Fig.  19  shows  them  perpendicular,  but  this  is  less  correct,  as 
Turner's  diagram  indicates  (Fig.  20).  The  glands  usually  bifurcate  at 
their  lower  ends,  and  two  may  have  a  common  mouth.  The  innermost 
layer  of  muscular  fibre  sends  up  prolongations  between  them — muscularis 
mucosae. 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


19 


The  connective  tissue  in  which  the  glands  are  embedded  consists  of 
delicate  round  and  spindle-shaped  cells,  the  former  being  more  abundant 
near  the  surface,  the  latter  deeper.  Fibrillated  bundles  of  connective 
tissue  lie  also  between  the  cells  and  pass  out  between  the  muscular  fibre 
of  the  uterine  wall  (Fig.  20). 

The  mucous  membrane  lining  the  cervix  is  different  in  arrangement 
and  structure  from  that  lining  the  cavity  of  the  uterus.  It  is  thrown  into 
numerous  folds  presenting  to  the  naked  eye  the  appearance  known  as  the 


Fig.  20. 

Vertical  section,  through  the  mncous  membrane  of  the  human  nterus  (Turner).  «,  columnar  epi 
thelinm,  the  cilia  are  not  represented ;  gg,  utricular  glands ;  ct,  ct,  interglandular  connective  tissue ;  t>r. 
Blood-vessels;  mm,  muscularis  mucosae.  (450) 

arbor  vitse,  which  consists  of  a  longitudinal  mesial  ridge  on  the  anterior 
and  posterior  walls,  from  both  sides  of  which  secondary  ridges  branch  off 
obliquely.  It  is  lined  throughout  with  a  single  layer  of  epithelium  (Fig. 
21)  which  is  ciliated  on  the  elevated  portion  of  the  ridges  but  is  columnar 
in  the  depressed  portions  (de  Sin£ty). 

The  glands  are  of  the  racemose  type  ;  and  consist  of  elongated  re- 
peatedly branching  ducts  which  extend  deeply  into  the  connective  tissue 
and  are  somewhat  dilated  at  their  extremities  (Ruge  and  Veit).  They 
open  on  the  ridges  and  furrows  of  the  mucous  membrane. 


20 


MANUAL    OF    GYNECOLOGY. 


There  is  a  sharp  line  of  demarcation  between  this  single  layer  of  epi- 
thelium (columnar  and  ciliated)  which  lines  the  cervical  canal  and  the 
epithelial  covering  of  the  external  surface  of  the  vaginal  portion,  and  this 
line  of  demarcation  corresponds  in  the  adult  to  the  os  extemum.  Beyond 
the  os  externum  the  epithelial  covering  has  all  the  characters  of  skin  ;  it 
consists  of  vascular  papillae  covered  with  many  layers  of  squamous  epithe- 
lium. The  vascular  papillae  are  not  easily  recognized  without  the  help  of 
reagents  (Euge  and  Veit).  The  epithelial  cells  are  like  those  found  in  the 
skin,  and  dovetail  into  one  another  by  denticulate  edges  (de  Sinety). 

It  is  a  disputed  question  whether  glands  are  present  on  the  vaginal 
aspect  of  the  normal  cervix  De  SinSty  says  he  has  never  met  with  them 


V 


Mucous  membrane  of  cervix  In  microscopical  section  (de  Sinety).  e,  ciliated  columnar  epithelium,  cilia 
not  shown  ;  y,  glands ;  m,  mvsculur  fibre ;  c,  blood-vessels  ;  ct,  connective  tissue  shown  only  at  one  part  of 
figure.  («<>/,) 

except  in  the  neighborhood  of  the  os  externum,  and  their  occurrence 
there  he  attributes  to  an  aversion  of  the  mucous  membrane  of  the  canal. 
Huge  and  Veit  also  consider  the  existence  of  glands  as  a  pathological  con- 
dition which  is  however  easily  induced. 

The  normal  histology  of  the  cervix  uteri  has  an  important  bearing  on 
the  pathology  of  the  so-called  ulcerations  and  on  laceration  of  the  cervix 
and  ectropium. 

FALLOPIAN   TUBES. 

The  Fallopian  tubes  are  two  tubes,  one  on  each  side  of  the  uterus,  run- 
ning sinuously  from  its  upper  angles  out  towards  the  side  of  the  pelvis 
(Figs.  22  and  53).  They  lie  enclosed  in  the  upper  free  margin  of  the 


ANATOMY    OF   THE    FEMALE    PELVIC    ORGANS.  21 

broad  ligaments,  and  vary  in  length  from  10  to  16  cm.  (3  to  4  inches). 
They  are  not  of  equal  length,  the  right  being  frequently  longer  than  the 
left 

After  leaving  the  superior  angle  of  the  uterus,  the  course  of  the  tube 
is  straight  for  about  2£  centimetres  (1  inch).  It  then  curves  outwards  and 
forwards,  and  finally  backwards  and  inwards,  so  that  the  whole  tube-  has 
roughly  the  shape  of  a  shepherd's  crook  (Fig.  22).  Three  parts  come  up 
for  consideration — the  isthmus,  the  ampulla,  and  the  pavilion  or  tim- 
briated  end. 

The  isthmus  is  the  straight  narrow  part  of  the  tube  (Fig.  22,  b),  which 


View  from  behind  of  the  lateral  angle  of  the  uterus,  with  part  of  the  left  broad  ligament,  Fallopian 
tube,  ovary,  and  parovarium  (Henle).  a,  uterus ;  6,  isthmus  of  Fallopian  tube ;  c,  ampulla ;  g,  has  par- 
ovarium  to  the  right,  and  fimbriated  end  of  Fallopian  tube  and  ovarian  nmbria  just  below  it ;  «,  ovary  ;  /, 
ovarian  ligament;  t,  infundibulo  pelvic  ligament.  (Vi) 

at  its  internal  end  opens  into  the  uterine  cavity,  and  has  a  lumen  barely 
admitting  a  bristle.  On  transverse  section  the  diameter  of  the  whole 
thickness  is  about  2  to  3  mm. 

The  ampulla  is  the  curved  and  thick  part  of  the  tube  (Fig.  22,  c), 
having  an  average  diameter  of  about  6-8  mm.,  with  a  lumen  admitting 
the  ordinary  uterine  sound. 

The  free  fimbriated  end  of  the  Fallopian  tube  (pavilion)  is  expanded 
and  funnel-shaped  ;  and  it  is  provided  with  primary  and  secondary  fim- 
brise  surrounding  the  opening  of  the  tube  to  which  they  converge.  One 
special  nmbria  runs  to  the  ovary  (Fig.  22). 

On  section  the  Fallopian  tube  is  seen  to  be  made  up  of  three  layers 


22  MANUAL    OF    GYNECOLOGY. 

from  without  inwards,  viz.,  peritoneal,  longitudinal  and  circular  unstriped 
muscular  fibres  (the  latter  being  inner),  and  mucous  membrane  lined 
with  ciliated  columnar  epithelium.  Connective  tissue  and  elastic  fibres 
lie  between  the  peritoneal  and  muscular  layers.  No  glands  exist  in  the 
mucous  membrane,  which  is  much  folded  in  a  longitudinal  direction  espe- 
cially in  the  ampulla. 

It  is  remarkable  that  the  ciliated  epithelium  lining  the  Fallopian  tube 
and  pavilion  should  be  continuous  with  the  squamous  epithelium  of  the 
peritoneum ;  and  that,  further,  there  is  direct  continuity  between  the 
vagina,  uterus,  Fallopian  tubes,  and  peritoneum, — so  that  the  peritoneal 
sac  in  the  female  is  not  closed  as  in  the  male. 

Parovarium  or  Organ  of  Rosenmiiller. — If  the  broad  ligament  be  held 
between  the  light  and  the  observer's  eye,  this  rudimentary  structure  will 
be  seen  enclosed  in  its  folds  in  the  space  between  the  ovary  and  ampulla 
(Fig.  22,  d).  It  consists  of  closed  tubules  lined  with  ciliated  epithelium, 
which  converge  towards  the  ovary  and  are  united  by  a  longitudinal  tube 
[v.  under  Development].  Their  pathological  degeneration  produces  the 
cystic  tumors  known  as  parovarian. 

OVAETJES. 

The  ovaries,  two  in  number,  lie  one  on  each  side  of  the  uterus,  pro- 
jecting markedly  through  the  posterior  layer  of  the  broad  ligament. 

Form,  Size,  and  Relations. — The  ovary  is  a  small  oval-shaped  body  about 
the  size  of  a  walnut,  the  weight  of  which  varies  from  60  to  135  grains. 
According  to  Farre  its  measurements  are  as  follows : — 

Longitudinal     Transverse     Perpendicular 
Diameter.        Diameter.         Diameter. 

Greatest,  .         .         .  2  in.          1^  in.  £  in. 

Smallest,  ....  1  in.  £  in.  £  in. 

Average,  .         .         .         .         1^  in.  f  in.  f  in. 

The  ovary  has  an  anterior  and  posterior  border,  and  an  upper  and 
lower  surface.  The  posterior  border  is  convex  and  free,  the  anterior  flat- 
tened and  attached  to  the  broad  ligament.  It  should  be  noted  that  this 
anterior  border  is  called  the  hilus,  and  that  the  blood-vessels  and  nerves 
enter  there. 

The  position  of  the  ovary  will  be  discussed  afterwards  (p.  57),  but  at 
present  it  is  sufficient  to  consider  it  as  lying  behind  the  broad  ligament 


ANATOMY    OF    THE    FEMALE    PELVIC    OKGANS.  23 

with  its  posterior  border  looking  backward  and  its  outer  end  farther  back 
than  its  uterine  one. 

Ligaments  of  the  Ovary. — In  addition  to  the  attachment  which  tt:e 
broad  ligament  gives  to  the  ovary,  two  important  ligaments  are  described 
— the  ovarian  ligament  and  the  infundibulo-pelvic  ligament. 

The  Ovarian  Ligament  (Fig.  22,  /)  is  about  3  cm.  (1  inch)  long,  and 
extends  from  the  inner  end  of  the  ovary  to  the  corresponding  upper  angle 
of  the  uterus,  just  below  the  uterine  origin  of  the  Fallopian  tube.  It  is  a 
longitudinal  fold  of  the  peritoneum  into  which  the  unstriped  muscular 
fibre  of  the  uterus  is  prolonged. 

The  Infundibulo-Pelvic  ligament  (Fig.  22,  i)  is  about  2  cm.  long,  and 
runs  from  the  outer  end  of  the  Fallopian  tube  to  the  side  wall  of  the 


Fig.  23. 

Section  of  cat's  ovary  (Schron).  The  free  border  of  the  ovary  is,  in  the  figure  above,  the  base  of  attach- 
ment— hiluB — below.  The  division  into  cortical  and  medullary  layers  is  indicated.  Note  smallest  Graafian 
follicles -at  surface,  and  larger  ones  not  so  superficial.  A  corpus  lutenm  lies  to  the  left  of  the  lulus.  (•/») 

pelvis.  It  is  simply  that  part  of  the  upper  margin  of  the  broad  ligament 
unoccupied  by  Fallopian  tube. 

The  Ovarian  Fimbria  (Fig.  22,  i)  prevents  the  separation  of  the  ovary 
and  infundibulum  tubse.  Thus  the  ovary  is  kept  in  position  by  its  attach- 
ment to  the  broad  ligament,  by  the  ovarian  and  by  the  infundibulo-pelvic 
ligaments.  Its  own  specific  gravity  has  also  a  share,  i.e.,  the  ovary  floats 
at  a  certain  level. 

Structure  of  the  Ovary. — The  ovary  is  covered  by  epithelium  differing 
from  the  squamous  epithelium  of  the  peritoneum  in  being  made  up  of 
columnar  cells  with  a  dull  lustre.  It  is  continuous,  however,  with  the 
peritoneal  epithelium,  the  line  of  contact  being  marked  by  a  whitish  and 
elevated  line.  The  epithelium  covering  the  ovary  is  known  as  the  germ- 


24  MANUAL    OF    GYNECOLOGY. 

epithelium.  This  distinctive  term  is  of  importance  in  connection  with  the 
development  of  the  ova  and  will  be  more  particularly  alluded  to  after- 
wards. 

On  section  and  microscopical  examination,  the  ovary  is  found  to  con- 
sist of  connective  tissue  with  the  structures  known  as  the  Graafian  follicles 
embedded  in  it,  along  with  blood-vessels,  nerves,  lymphatics,  and  some 
unstriped  muscular  fibre.  These  are  enclosed  in  the  epithelial  covering 
already  described.  The  connective  tissue  is  divided  into  a  cortical  and 
medullary  layer  ;  the  former  lying  beneath  the  peritoneum,  the  latter  be- 
ing at  and  near  the  hilus  (Fig.  23).  The  medullary  layer  is  very  vascular, 


Fie-  24. 

Section  through  the  cortical  pnrt  of  the  ovary  (Turner).  «.  perm  epithelium;  »,  »,  ovarian  stroma; 
1,  1,  large-sized  ovarian  follicles ;  2,  2,  middle-sized ;  and  3,  3,  smaller-sized  Graafian  follicles ;  o,  ovum 
vf ithin  Graafian  follicles ;  v,  v,  blood-vessels  in  the  stroma ;  g,  cells  of  membrana  granulosa. 

and  has  some  unstriped  muscular  fibre  round  the  branches  of  the  ovarian 
artery  (Fig.  24). 

The  Graafian  follicles  are  scattered  through  the  whole  substance  of  the 
ovary.     The  following  points  should  be  carefully  noted : 

a.  The  younger  and  smaller  Graafian  follicles  lie  in  the  cortical  layer. 
Their  size   is   generally  about  -j-^oth   in-»  and   they   exist  in   immense 
numbers.     According  to  careful  estimates,  the  ovary  of  a  female  infant 
may  contain  40,000  to  70,000  such  follicles. 

b.  The  larger  follicles  are  much  fewer  in  number  and  lie  deeper  in  the 
ovary.     Size  -g^th  to  y^^th  in. 

c.  There   are   also   still  larger  follicles  nearer  the  surface   than   the 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


L'O 


latter.     These  have  advanced  from  the  deeper  layer  (vide  under  Menstru- 
ation). 

Structure  of  a  Graafian  Follicle.— This  consists  of 

1.  An  envelope  of  connective  tissue  with  capillary  vessels  ; 

2.  The  Menibrana  granulosa,  a  layer  of  nucleated  columnar  epithelial 
cells  forming  the  discus  proligerus  at  one  part ; 

3.  Fluid. 

The  ovum  (size  T-J-ff  to  y-^  in.  diameter)  lies  in  the  discus  proligerus  ; 
it  has 

1.  External  envelope — zona  pellucida, 

2.  Yelk  protoplasm, 

3.  Germinal  vesicle  (Tf^th  in.  diameter), 

4.  Germinal  spot  -g^Vo^h  in.  diameter. 


THE  VAGINA. 


The  vagina  is  a  mucous  slit  in  the  pelvic  floor,  extending  from  the 
hymen  to  the  cervix  uteri,  and  lying  between  the  urethra  and  bladder  in 


c 


Fig.  25. 


front  and  the  rectum  behind.     In  the  upright  posture  it  makes  an  angle 
of  about  (50  '  with  the  hori/on,  i.e.,  it  is  nearly  parallel  1o  the  pelvic  brim. 
The  vagina  lias  two  walls,  an  anterior   and  posterior,  which   are   con- 
tinuous at  their  sides.      The  anterior  vaginal  wall   is  triangular  in   shape, 


26 


MANUAL    OF    GYNECOLOGY. 


the  base  being  above.  Its  lower  limit  is  marked  out  by  the  hymen.  At 
its  upper  end  it  is  reflected  down  to  a  very  small  extent  on  the  anterior  lip 
of  the  cervix  uteri,  the  anterior  fornix  being  thus  formed  (Fig.  25).  It  is 
closely  incorporated  with  the  urethra,  but  between  it  and  the  posterior 
aspect  of  the  bladder  there  is  loose  connective  tissue.  Its  length  is  about 
5  cm.,  i.e.,  2-2£  inches. 

The  mucous  membrane  of  the  wall  is  arranged  in  folds  roughly  trans- 
verse.    At  its  lower  end  is  a  vertical  mesial  single  or  double  thickening 


Pig.  2G. 

Anterior  vaginal  wall  and  mnltiparous  cervix,  looked  at  from  behind  (Henle).    o,  urethra!  orifice ;  6, 
anterior  vaginal  column;  c,  cervix  uteri.  (Vi) 

of  the  mucous  membrane,  about  2  cm.  long,  known  as  the  anterior  vagi- 
nal column  (Fig.  26,  b).  This  begins  near  the  urethra!  orifice  or  about 
1£  cm.  above  it.  According  to  Budin,  the  columns  are  prolonged  on  the 
hymen. 

The  posterior  vaginal  wall  is  triangular  in  shape  and  extends  from  the 
vaginal  orifice  upwards  to  the  cervix  uteri  upon  which  it  is  reflected,  thus 
forming  the  posterior  fornix  vaginse,  which  is  deeper  than  the  anterior 


ANATOMY    OF    THE    FEMALE   PELVIC    ORGANS. 


27 


one.  Its  length  is  about  7£  cm.  (3  inches),  i.e.,  about  2£  cm.  (nearly  1 
inch)  longer  than  the  anterior.  It  is  also  transversely  rugous,  and  has  a 
posterior  column  analogous  to  the  anterior,  but  smaller. 

While  the  direction  of  the  anterior  vaginal  wall  is  almost  straight,  that 
of  the  posterior  vaginal  wall  is  sigmoid  (Fig.  27).  The  curve  varies,  how- 
ever, according  to  the  position  of  the  uterus,  and  the  fulness  or  emptiness 
of  the  adjacent  bladder  and  rectum. 

When  the  bladder  and  rectum  are  empty  we  find  the  direction  of  the 
vagina  parallel  to  the  pelvic  brim.  When  the  bladder  is  distended  the 


Diagram  of  vertical  mesial  section  of  female  pelvis,  showing  sigraoid  curve  of  posterior  vaginal  wall 
(Schultze).  (V4) 

vagina  is,  chiefly  at  its  upper  part,  driven  nearer  the  sacrum  ;  while  if  the 
rectum  be  distended,  the  vaginal  axis  may  be  almost  perpendicular. 

Structure  of  Vagina. — The  vaginal  wall  on  section  and  microscopical 
examination  is  found  to  consist  of  mucous  membrane,  made  up  of  epithe- 
lium (the  superficial  layer  being  squamous  and  nucleated,  the  deeper 
layer  cylindrical  and  with  elongated  nuclei)  ;  of  connective  tissue,  elastic 
tissue,  and  some  unstriped  muscular  fibre.  External  to  this  He  two 
layers  of  unstriped  muscular  fibre  ;  the  inner  longitudinal,  the  outer 


28 


MANUAL    OF    GYNECOLOGY. 


circular  (Henle).  Breisky  alleges  the  inner  to  be  circular.  There  are 
no  proper  glands  in  the  vagina,  but  gland-like  crypts  and  lymph  follicles 
exist  (Lowenstein)  (Fig.  29).  The  whole  is  surrounded  by  loose  connec- 
tive tissue  (Fig.  29). 

As  already  stated,  the  vagina  is  a  mere  slit  in  the  pelvic  floor,  although 


28.  Fiff.29. 

Horizontal  section  of  the  pelvic  floor  at  Horizontal  section  of  the  posterior  wall  of 

the  pelvic  outlet  (Henle).     Ua,  urethra;  bladder  and  the   anterior  wall  of  the  vagina 

Fa,  vagina;  K,  rectum ;  L,  levator  ani.  (Henle).    («/,)  a,  epithelium  of  the    bladder; 

&,  mucosa ;  c,  layer  of  circular  fibres ;  ii,  layer  of 
longitudinal  fibres ;  e,  loose  tissue ;  /,  layer  of 
circular  fibres;  g,  layer  of  longitudinal  fibres; 
A,  mucosa ;  »',  epithelium  of  vagina. 

it  is  often  erroneously  described  as  a  tube  or  cavity.  On  vertical  sec- 
tion, as  Fig.  25  shows,  it  appears  as  a  mere  linear  slit ;  while  on  trans- 
verse section  it  is  H-shaped,  or  crescentic  (Figs.  28  and*46).  Of  course 
the  vagina  is  eminently  dilatable  and  its  walls  separable,  as  will  be  more 
fully  considered  under  the  structural  anatomy  of  the  pelvic  floor,  but  this 
dilatation  or  separation  is  the  result  of  posture  with  manipulation,  or  of 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        29 

Parturition.     Whatever  posture  a  woman  may  assume,  the  vagina  on  sec- 
tion is  slit-like,  unless  in  certain  exceptional  instances. 


THE    BLADDER. 

Position. — The  empty  female  bladder  lies  behind  the  pubis  and  in  front 
of  the  vagina,  and  consists  of  the  urethra  and  bladder  proper. 

The  urethra  is  a  straight  slit  (some  describe  it  as  sigmoid)  about  If 
inches  long,  with  thick  walls  closely  incorporated  with  the  anterior  vagi- 
nal wall  behind.  It  runs  parallel  to  the  plane  of  the  pelvic  brim.  Its 


Efe,  3d 

Transverse  section  of  urethra  much  enlarged    (Skene).     a,  urethra;    6,  6,  glands  described  by  .^kene  ; 
c,  vein  ;  d,  artery. 

lower  opening  is  known  as  the  meatus  urinarius,  the  position  of  which 
has  been  already  considered  in  the  section  on  the  External  Genitals  ;  its 
upper  opening  is  at  the  neck  of  the  bladder.  On  section  and  microscopi- 
cal examination,  its  mucous  membrane  is  found  covered  with  squamous 
epithelium  in  its  lower  part ;  while  higher  up  it  is  like  that  of  the  bladder, 
and  is  very  rich  in  elastic  fibres.  There  is  a  double  layer  of  nn*tr>p'tl 
muscular  fibre,  tlfe  longitudinal  layer  being  internal  and  the  circular  out- 
side ;  and,  according  to  Ufielman,  a  circular  (inner)  and  longitudinal  layer 
of  striped  muscle,  which  stretches  from  the  neck  of  the  bladder  to  within 
H  cm.  of  the  meatus  urinarius.  Luschka  also  describes  a  special  sphinc- 


30 


MANUAL    OF    GYNECOLOQY. 


ter  of  the  vaginae  and  urethral  orifices.  It  should  be  further  noted  that 
the  mucous  membrane  is  folded  longitudinally  and  contains  mucous 
glands  lined  with  cylindrical  epithelium,  papillae  and  lacunae,  and  also  vil- 
lous  tufts  near  the  meatus  ;  and  that  there  is  a  submucous  layer  between 
the  mucous  membrane  and  unstriped  muscle,  containing  many  veins. 
Recently  Skene,  of  New  York,  has  described  two  tubules  in  the  female 
urethra.  They  lie  on  each  side  "near  the  floor  of  the  female  urethra,  and 
extend  up  from  the  meatus  urinarius  for  about  £  inch  (Figs.  30  and  31). 


Urethra  laid  open  from  above,  showing  glands  with  probes  passed  in  (Skene). 

They  lie  beneath  the  mucous  membrane,  and  in  the  muscular  walls  of  the 
urethra."    We  have  in  section  of  the  female  urethra  : — 

mucous  membrane ; 

submucous  layer ; 

muscular  layer,  longitudinal  and  circular,  unstriped  ; 

do.  do.        striped  (Uftelman). 

External  to  these  there  is  the  anterior  vaginal  wall  behind,  and  loose 
tissue  in  front. 

According  to  Henle,  the  closed  urethral  slit  is  on  section  transverse 
near  the  bladder,  sagittal  at  the  meatus,  and  star-shaped  between  these 
two  points. 

In  the  bladder  proper  we  have  three  openings,  the  internal  orifice  of 
the  urethra  and  the  orifices  of  the  two  ureters.  The  latter  lie  one  on  each 
side,  about  l£  inches  from  the  internal  orifice.  These  openings  give  us 
the  landmarks  for  the  division  of  the  bladder  into  neck,  base,  and  body. 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGAN'S.        31 

All  above  the  lines  joining  the  ureteric  openings  and  the  centre  of  the 
symphysis  is  the  body  ;  all  below  is  the  base,  and  that  portion  between 
the  ureteric  openings  and  the  internal  orifice  is  the  trigone.  Just  above 
the  ureters  is  the  baa  fond  (Skene). 

The  wall  of  the  bladder  is  made  up  of  three  layers,  viz.,  a  mucous,  a 
muscular,  and  a  peritoneal. 

The  mucous  membrane  consists  of  connective  tissue  lined  by  several 
layers  of  transitional  or  multiform  epithelium  (Fig.  32).  It  is  arranged  in 


Fig.  32. 

Epithelial  cells  from  the  mucous  membrane  of  the  bladder.     Tho=c  in  the  upper  row  are  the  s;.i<i'M:<  v.l 
squamous  cells  ;  those  in  the  lower  row  are  the  peculiar  cells  of  the  middle  stratum  (Turner). 

folds,  except  over  the  trigone  and  openings.     The  folds  or  rugo3  are  due 
to  the  laxity  of  the  submucous  coat. 

The  muscular  coat  of  the  bladder  is  of  the  unstriped  variety,  and  lias 
a  complicated  arrangement.  There  are  external  longitudinal  iibres.  cir- 
cular fibres  within  these,  and  an  internal  longitudinal  layer  on  which 
rests  the  submucous  coat.  It  is  disputed  whether  there  is  a  sphincter  at 
the  neck  of  the  bladder.  Probably  there  is  not  ;  but  the  puckering  of 
the  mucous  membrane  at  the  neck  is  alleged  to  have  a  valve-like  function. 

The  peritoneal  covering  of  the  bladder  Mill  be  considered  subse- 
quently. 

The  relation  of  the  ureters  to  the  bladder  is  of  importance.  Garrigurs 
has  recently  investigated  this  subject,  owing  to  its  importance  in  Gashc 
Elytrotomy. 

"  In  this  obstetric  operation,  employed  in  eases  where  craniotomy  or 
the  cacsarean  section  is  the  alternative,  the  operator  cuts  through  the  ab- 
dominal walls  with  the  same  incision  as  that  for  ligature  of  the  external 
iliac  artery.  The  peritoneum  is  pushed  aside  and  the  vagina  partly  cut 
and  partly  torn  by  an  oblique  incision.  The  child  is  then  extracted.  In 
some  of  the  cases  the  bladder  or  ureter  lias  bren  torn  into." 


.12  MANUAL    OF    GYNECOLOGY. 

According  to  him  "  the  ureter  does  not  lie  in  the  broad  ligaments,  it 
does  not  keep  the  same  direction  on  reaching  the  wall  of  the  bladder,  and 
it  does  not  lie  close  up  to  the  wall  of  the  cervix,  all  of  which  is  taught  by 
anatomical  authorities.  After  having  crossed  the  iliac  vessels  the  ureters 
diverge,  running  downward,  backward,  and  a  little  outward  on  the  wall  of 
the  pelvis,  behind  the  broad  ligaments  to  a  point  near  the  spina  ischii. 
Then  they  bend  downward,  forward,  and  considerably  inward  so  as  to  con- 
verge toward  the  bladder.  They  pass  beneath  the  base  of  the  broad  liga- 
ment, lying  in  the  abundant  cellular  tissue  found  in  this  locality.  They 


Relations  of  ureters  (Garrlgues).  U,  uterus ;  vr,  ureter ;  B.  bladder ;  «,  urethra  ;  P,  vagina ;  T,  Fallopian 
tube ;  O,  ovary ;  6,  broad  ligament ;  r,  round  ligament ;  ct,  connective  tifisue  :  x,  incision  of  vagina  in  gas- 
tro-elytrotomy.  (2/8) 

cross  the  cervix  at  some  distance  from  behind,  at  an  acute  angle,  so  as  to 
come  in  front  of  and  below  it.  They  lie  outside  and  above  the  anterior 
part  of  the  side  wall  of  the  vagina,  on  a  spot  as  large  as  the  tip  of  the 
finger.  On  reaching  the  wall  of  the  bladder  they  turn  rather  sharply 
inward  and  go  less  downward  until  they  open  with  a  small  slit  into  the 
interior  of  the  bladder  at  the  outer  angle  of  the  trigonum  vesicce.  But  on 
dissecting  the  bladder  from  the  uterus  and  vagina,  their  substance  is  seen 
to  continue  running  as  a  solid  ridge  between  the  two  apertures,  and  form- 
ing the  base  of  the  trigone  (June's  inter-ureteric  ligament)."  (See  Fig.  33.) 
Shape  of  empty  Bladder  and  Changes  in  its  Position. — The  empty  female 
bladder  lies  completely  behind  the  pubis,  and  has  its  fundus  covered  by 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


peritoneum.  When  empty  and  viewed  in  mesial  section  it  may  present 
one  of  two  shapes.  In  the  large  majority  of  specimens  figured,  it  forms 
with  the  urethra  a  Y  shape  on  sagittal  mesial  section.  The  oblique  legs  of 
the  Y  may  be  about  equal  in  size,  or  the  posterior  may  be  shorter  (Figs. 
40,  34).  This  form  is  so  common  that  it  has  been  accepted  hitherto  by 
all  authors  as  the  normal  one.  In  certain  cases,  however,  insignificant  in 


.Pier. 

Vertical  mesial  Fection  of  female  pelvis,  showing  Y  shape  of  bladder  (Fiirst).     ('/a) 

number  as  compared  with  the  former,  the  empty  bladder  cavity  forms 
with  the  urethra  a  continuous  tube  on  vertical  mesial  section  (Fig.  35).  In 
such  cases  it  is  oval  in  shape,  corrugated,  and  firm  to  the  touch.  This  latter 
shape  is  the  one  always  found  in  the  lower  animals,  such  as  the  rabbit 
and  dog,  and  is  the  only  one  seen  in  the  human  foetus.  If,  therefore,  the 

pelvic  floor  of  a  woman  be  viewed  on  its  peritoneal  aspect,  the  fundus  of 
VOL.  I.— 3 


34 


MANUAL    OF    GYNECOLOGY. 


the  empty  bladder  will  be  found  to  be  almost  always  large  and  concave, 
while  in  a  few  cases  it  is  small  and  convex.  In  the  former  case,  the  inner 
surface  of  the  upper  segment  of  the  bladder,  large  in  area,  is  in  contact 
with  the  surface  of  the  lower  segment ;  in  the  latter,  the  anterior  and  pos- 
terior inner  walls,  small  in  area,  touch  one  another. 

It  is  probable  that  when  the  bladder  has  the  Y  shape  on  section,  it  is 
in  diastole  (Fig.  34)  ;  and  when  the  oval  shape  (Fig.  35),  it  has  been 
caught  in  systole.  The  bladder  contracts  to  expel  the  urine  and  then  re- 
laxes. Between  the  acts  of  urination  the  bbdder  is  therefore  only  a  flaccid 
sac.  Some  additional  facts  as  to  the  position  and  distention  of  the  bladder 
are  best  considered  further  on,  under  the  structural  anatomy  of  the  pelvic 
floor.  We  may  here  state,  however,  that  (1)  when  empty,  in  the  non-par- 


Vertical  mesial  section  of  female  pelvic  floor,  showing  contracted  bladder  in  a  suicide  (Braune).  ('/a) 
The  peritoneum  descends  in  front  of  the  uterus  to  6  and  behind  it  to  rf ;  b  a  and  d  c  are  loose  extra-peri- 
toneal tissue. 

turient  female,  it  is  behind  the  pubis  (Fig.  32) ;  (2)  it  is  drawn  above  the 
pubis  in  the  parturient  female  ;  (3)  it  is  tilted  above  the  pubis  in  retro- 
version  of  the  gravid  uterus. 

The  so-called  ligaments  of  the  bladder  are  false  and  true.  The  false 
are  formed  of  peritoneum  and  will  be  considered  under  the  peritoneum 
of  the  pelvic  floor.  The  true  ligaments  are  formed  of  the  pelvic  fascia. 

RECTUM. 

The  Rectum  extends  from  the  left  sacro-iliac  synchondrosis,  where  the 
sigmoid  flexure  of  the  colon  terminates,  to  the  anus.  It  curves  downwards, 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


35 


backwards,  and  inwards,  to  about  the  third  sacral  vertebra.  This  is  known 
as  the  first  part  of  the  rectum ;  it  is  completely  covered  by  peritoneum, 
which  forms  the  meso-rectum.  The  peritoneum  is  reflected  from  the  rec- 
tum on  to  the  upper  part  of  the  vaginal  wall,  about  3  inches  above  the  vagi- 
nal orifice.  Thereafter,  the  rectum  lies  in  relation  anteriorly  to  the  pos- 
terior vaginal  wall  to  which  it  is  loosely  attached  until  about  1£  inches 
from  the  anus. 

The  rectum  is  made  up  of  peritoneal  investment ;  unstriped  muscular 


Fig.  36. 
Rectum  inflated  (Chadwick).    o  6,  sphincter  tertius  ;  c .  ampulla  of  rectum. 

fibre  in  two  layers,  longitudinal  and  circular,  the  former  being  the  outer  ; 
a  submucous  coat  ;  and  a  mucous  lining  with  its  musculares  mucosa3, 
columnar  epithelium,  no  villi,  but  with  Lieberkuhnian  follicles  closely  set 
together.  At  the  upper  limit  of  the  anus,  the  circular  fibres  are  very  well 
marked  and  constitute  the  sphincter  ani  internus  (Fig.  37). 

Certain  oblique  folds  in  the  rectum — consisting  of  mucous,  sub- 
mucovis,  and  circular  unstriped  muscular  coats — are  of  special  interest. 
One  exists  H  inches  from  the  anus,  another  is  near  the  sacral  promontory, 
and  one  is  intermediate  (Turner).  The  lowest  (the  valve  of  Houston  or 
sphincter  ani  tertius  of  Hyrtl)  has  been  described  by  Chadwick  of  Boston, 


MANUAL    OF    GYNECOLOGY. 


as  being  not  an  entire  circular  fold  but  made  up  of  two  semicircular  con- 
strictions, one  011  the  anterior  wall  and  one  on  the  posterior  an  inch 
higher  up  (Fig.  3G). 

The  Anus  is  that  part  of  the  rectum  at  its  external  orifice.     It  is  about 


Ffe  sr. 

Perpendicular  section  through  the  end  of  the  rectnm  enlarged  (Ruedingcr).  I,  mucous  membrane  of 
the  rectum  :  2,  boundary  between  mucous  membrane  and  skin  of  buttock  ;  3,  fat ;  4,  levator  ani ;  5,  sphinc- 
ter ani  externus ;  9,  fibres  of  longitudinal  layer  separating  external  sphincter  into  parts  ;  7,  sphincter  ani 
internus ;  8,  longitudinal  fibres  of  muscular  coat,  which  radiate  outwards  at  9 ;  13,  longitudinal  fibres  of  mn.s- 
cularis  mucosas  which  radiate  outwards  at  12 ;  11  circular  fibres  of  muscular  coat ;  6,  It),  and  14,  slips  of 
muscular  fibre  passing  into  tissue  beyond. 

an  inch  long,  and  has  its  long  axis  directed  backwards  and  cutting  the 
axis  of  the  vagina  at  about  a  right  angle.  The  rectum,  therefore,  when  in 
contact  with  the  posterior  vaginal  wall,  closely  follows  its  direction,  but  at 
about  1  inch  from  the  anus  turns  sharply  backwards.  There  is  thus  left 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS.  37 

between  it  and  the  last  14-  inch  or  so  of  the  posterior  vaginal  wall,  an  an- 
gular interspace  to  be  filled  up  by  the  structure  known  as  the  perineal 
body. 

Fig.  37,  from  Ruedinger,  shows  the  arrangement  of  the  voluntary  and 
involuntary  muscle  of  the  anus.  The  division  of  the  external  sphincter 
into  two  parts,  and  the  separation  of  the  lower  division  (5)  into  compart- 
ments by  fibres  from  the  longitudinal  unstriped  layer  (9),  are  noteworthy. 
Similarly  the  internal  sphincter  (7)  is  divided  into  compartments  by  fibres 
from  the  muscularis  mucostc  (13).  Near  the  anal  orifice  the  mucous  mem- 
brane has  certain  perpendicular  folds  in  it  known  as  the  Columua1  Mor- 
gagni,  with  depressions  between  these — the  Sinus  Morgagni  iFig.  2). 


I'EUIXEAL  1JODY. 

The  posterior  vaginal  wall  is  in  contact  with  the  anterior  rectal  wall, 
for  about  li  inches  above  the  apex  of  the  perineal  body,  there  being  only 
loose  tissue  between.  The  anus  has  its  long  axis  directed  backwards, 
while  the  vaginal  axis  runs  forwards  ;  we  thus  get  a  pyramidal  space  filled 
up  by  the  structure  known  as  the  Perineal  body  (Henle  and  Savage). 

The  Perineal  body  is  made  up  of  muscular  insertions  and  origins 
(striped  and  unstriped  >,  and  fibrous  and  elastic  tissue.  Its  base  is  cov- 
ered by  the  skin  lying  between  the  anus  and  vagina  ;  its  anterior  side  is 
behind  the  posterior  vaginal  wall  ;  its  posterior  side?  lies  in  front  of  the 
anterior  rectal  wall  and  anus  ;  while  Literally,  it  is  bounded  by  fat.  The 
voluntary  muscles  passing  into  it  are  the  Sphincter-sun,  Transversus  peri- 
nei,  Bulbo-cavemosus,  and  Levator-ani  (Fig.  2). 

This  Perineal  body  measures  about  I.1,-  inches  (4  cm.)  vertically,  the 
same  transversely,  and  :;  in.  antero-posteriorly.  If  a  straight  line  be  made 
in  join  the  tip  of  the  coccyx  and  the  subpubic  ligament,  it  will  just  clear 
the  apex  of  this  structure. 

Its  functions  are  important,  but  have  been  both  exaggerated  and  un- 
derrated. It  gives  a  fixed  point  for  many  muscles,  prevents  pouching  of 
the  rectum  forwards,  and  strengthens  that  part  of  the  pelvic  floor  which 
has  no  posterior  bony  support. 

Its  special  significance,  however,  will  be  considered  further  on. 

At  present,  the  nomenclature  in  regard  to  the  "Perineal  region  "  is 
exceedingly  vague  ;  as  the  term  Perineum  is  used  in  varying  senses  by 
accoucheurs,  especially  in  regard  to  the  tears  caused  by  Parturition.  It  is 


38  MANUAL    OF    GYNEOOLOGY. 

better  to  be  precise,  and  speak  of  tears  of  the  hymen,  fourchette,  and 
perineal  body,  instead  of  saying  "perineal  tears."  The  surface  between 
the  anal  and  vaginal  orifices  is  not  the  perineum,  but  the  "skin  over  the 
base  of  the  perineal  body  "  and  "  the  fourchette." 

PERITONEUM. 

This  is  the  thin  serous  covering  of  the  concave  surface  of  the  pelvic 
floor,  uterus,  and  its  appendages,  etc.     A  knowledge  of  its  disposition  ia 


Fig.  88. 

Frozen  section  showing  peritoneum  (Fttrst).     The  dotted  line  indicates  peritoneum  in  this  and  Figs.  36-44. 
a,  anus;  b,  vagina;  c,  bladder;  d,  uterus;  e,  below  pouch  of  Douglas.     Symphysis  pubis.    (Va) 

of  the  highest  importance  to  the  Gynecologist.     This  is  best  considered 
as  follows. 

1.   The  Pelvic  Peritoneum  as  followed  in  the  Vertical  Mesial  Line. — The 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 

Peritoneum  of  the  anterior  abdominal  wall  is  reflected,  at  a  point  a  little 
above  the  symphysis  pubis,  on  to  the  fundus  of  the  empty  bladder  (Figs. 
38  and  39).  It  passes  downwards  over  the  posterior  surface  of  the  bladder, 
from  which  it  crosses  on  to  the  anterior  surface  of  the  uterus  at  a  point 
about  the  level  of  the  os  internum.  From  this  it  passes  up  over  the  ante- 
rior surface  of  the  uterus.  Thus  there  is  formed  a  vesico-uterine  pouch, 
containing  no  small  intestine  either  when  the  bladder  is  in  systole  or  in 


Fig.  39. 

Frozen  section  showing  peritoneum  in  contracted  bladder  (Heitzmann). 

diastole  (Figs.  38  and  39).  When  the  bladder  has  the  Y-shape  patho- 
logically produced  [vide  postea],  the  peritoneum  passes  directly  backwards 
across  the  fundus  of  the  bladder  and  on  to  the  anterior  surface  of  the 
uterus  at  or  below  the  level  of  the  os  internum  (Fig.  40).  There  is  thus 
produced  a  utero-abdominal  pouch  (Fig.  40). 

The  peritoneum  covers  the  whole  of  the  anterior  surface  of  the  uterus 
above  the  os  internum,  passes  over  the  fundus  and  down  the  posterior 
surface,  which  it  covers  almost  completely.  From  this  it  descends  still 


40  MANUAL    OF    GYNECOLOGY. 

deeper,  on  to  the  posterior  aspect  of  the  posterior  vaginal  wall  for  about 
one  inch  (Fig.  38).  The  amount  of  its  dip  varies,  however.  In  one  sec- 
tion by  Pirogoff  (Fig.  41)  the  peritoneum  runs  down  on  the  posterior 
vaginal  wall  till  within  about  an  inch  from  the  vaginal  orifice.  This  ex- 
tent of  posterior  peritoneal  duplicature  is,  of  course,  abnormal.  The 
depth  of  the  peritoneal  pouch  behind  the  uterus  is  greater  on  the  left  side 
than  on  the  right.  That  its  depth  varies  is  quite  evident  on  section,  as  in 
some  sections  it  ends  at  the  level  of  the  posterior  fornix  (Fig.  39),  while 


Fig.  40. 

Section  (spirit-hardened)  showing  peritoneum  when  uterus  is  drawn  back  by  posterior  pelvic  cellulitis 

(Hart). 

in  others  it  is  seen  passing  as  deeply  as  has  been  already  described  (Figs. 
38,  41).  This  descent  of  the  peritoneum  behind  the  uterus  is  of  the  high- 
est importance  practically,  and  forms  the  well-known  pouch  of  Douglas. 
This  pouch  is  best  defined  as  follows  : — Its  upper  lateral  boundaries  are 
the  utero-sacral  ligaments ;  its  anterior  boundary  is  the  uppermost  inch 
of  the  posterior  vaginal  wall  and  posterior  aspect  of  the  supra-vaginal 
portion  of  cervix ;  its  posterior  boundary  is  the  sacrum  and  rectum,  cov- 
ered by  peritoneum.  It  is  the  lowest  part  of  the  peritoneal  cavity,  and 
from  its  relation  to  the  posterior  vaginal  wall  can  be  explored  through  the 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        41 

posterior  vaginal  fornix.  It  is  partially  filled  by  intestine  when  the  uterus 
lies  to  the  front,  which  becomes  displaced  when  the  uterus  is  retroverted 
or  retroflected. 

2.  Tfie  Disposition  of  the  Pelvic  Peritoneum  at  the  sides  of  the  Uterus. 
The  Broad  Ligaments. — At  the  sides  of  the  uterus,  the  peritoneum  clothing 
its  anterior  and  posterior  surfaces,  passes  outwards  and  somewhat  back- 


Kg.  41. 

Peritoneum  dipping  abnormally  deep  between  rectum  and  vagina  (PirogoS). 

wards  to  the  sides  of  the  pelvis  in  front  of  the  sacro-iliac  synchondrosis. 
In  this  way  we  get  two  laminae  of  peritoneum  nearly  in  apposition,  which 
become  more  separated  at  their  junction  with  the  pelvic  floor  and  sides  of 
the  pelvis.  These  are  the  broad  ligaments  of  the  uterus. 

Just  within  their  upper  free  margin  the  Fallopian  tubes  are  placed. 


42  MANUAL    OF    GYNECOLOGY. 

That  part  of  the  free  margin  not  occupied  by  the  Fallopian  tube  forms 
the  infundibulo-pelvic  ligament  of  the  ovary  (Figs.  22  and  53).  Project- 
ing through  the  posterior  lamina  of  the  broad  ligament  is  the  ovary,  cov- 
ered by  its  germ-epithelium.  The  ovarian  ligament  and  parovarium  have 
already  been  described  under  the  ovary  and  Fallopian  tube. 

Between  the  layers  of  the  broad  ligament  lie  connective  tissue,  un- 
striped  muscle,  blood-vessels,  and  lymphatics.  According  to  M.  Guerin, 
the  broad  ligaments  enclose  a  small  space  shut  off  from  the  rest  of  the 
cellular  tissue  of  the  pelvis,  and  he  denies  that  as  yet  there  is  proof  of 
any  special  diagnosable  inflammatory  affection  of  the  broad  ligaments. 


Fig.  42. 

Relation  of  peritoneum  to  bladder  at  end  of  pregnancy  (Braune).     (Frozen.)    a,  vaginal  entrance ; 
6,  uterus ;  c,  anus ;  d,  bladder ;  e,  symphysis. 

Guerin  alleges  that,  by  inflation,  it  can  be  demonstrated  that  the  broad 
ligaments  are  thus  shut  off — a  fact  denied  by  other  observers. 

The  position  of  the  broad  ligaments  varies  according  to  that  of  the 
uterus.  When  the  uterus  is  normal  in  position,  i.e.,  lying  to  the  front, 
their  posterior  surfaces  look  upwards  and  somewhat  backwards,  and  they 
run  outwards  and  backwards  as  already  described.  Displacement  of  the 
uterus  backwards  causes  their  coincident  displacement,  and  in  pregnancy 
they  are  drawn  up  and  lie  almost  vertically.  Pathologically,  they  cicatrize 
after  inflammatory  attacks  causing  unilateral  deviations  of  the  uterus. 

3.   TJie  Pelvic  Peritoneum  on  the  Side-walls  of  the  Pelvis. — The  Pelvic 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS.  43 

peritoneum  clothes  the  side-walls  of  the  Pelvis.  It  dips  down  least  at  the 
side  of  the  bladder  and  most  at  the  utero-sacral  ligaments. 

Although  the  Pelvic  Peritoneum  has  been  described  in  three  sections, 
it  must  of  course  be  kept  in  mind  that  it  is  a  continuous  membrane,  with 
no  breaks  in  its  continuity. 

Some  special  facts  about  the  peritoneum  should  now  be  noted. 

1.  As  to  the  Bladder. — When  the  bladder  is  distended,  the  peritoneum 
is  stripped  off  the  lower  part  of  the  anterior  abdominal  wall  to  an  extent 
varying  with  the  distention  (Fig.  44).     During  parturition,  the  Perito- 
neum is  drawn  off  the  bladder  (Fig.  43)  (Hart). 

2.  As  to  the  Rectum. — Its  upper  part  is  completely  invested  by  peri- 


Fig.  '43. 

llelation  of  peritoneum  to  bladder  during  parturition  (Braune).    a,  vagina ;  d,  bladder ;  c,  anus. 

toneum  ;  the  second  part  is  only  partially  covered,  i.e.,  the  peritoneum 
gradually  leaves  the  rectum,  quitting  first  the  posterior  surface,  then  the 
sides,  and  finally  passing  from  the  anterior  surface  on  to  the  posterior 
vaginal  wall  as  already  described. 

Over  the  bladder  and  anterior  abdominal  wall  the  peritoneum  is  easily 
separable.  According  to  Spiegelberg,  above  the  os  internum  uteri  pos- 
teriorly it  is  closely  blended  with  the  uterus,  below  this  quite  loosely. 

Practical  Points. — In  no  operative  procedure  involving  the  anterior 
vaginal  wall  can  the  peritoneal  cavity  be  opened  into.  In  the  upper  third 
or  so  of  the  posterior  vaginal  wall  the  peritoneum  may  be  opened  into. 
This  has  indeed  been  done  by  the  most  skilful  operators,  but  the  risks  at- 


44  MANUAL    OF    GYNECOLOGY. 

tending  it   are  not  so  considerable  as  usually  alleged,  especially  when 
drainage-tubes  are  employed.     When  the  fingers  are  passed  into  the  pos- 


Kg.  44. 


Relation  of  bladder  and  peritoneum  when  bladder  is  distended  (Pirogoff).    a,  vagina  ;  6,  nterns ;  c,  anus ; 

d,  bladder;  «,  symphysis. 

terior  fornix  vaginae,  only  about  £  inch  of  tissue  intervenes  between  them 
and  the  peritoneum.  The  possibility  of  there  being  a  deep  dip  of  the  peri- 
toneum, as  shown  at  Fig.  41,  should  not  be  forgotten. 

CONNECTIVE  TISSUE   OF  PELVIS. 

By  this  we  understand  (I.)  the  Fascia  described  so  elaborately  by  the 
human  anatomist  as  the  Pelvic  Fascia  ;  and  (II.)  the  loose  Connective 
Tissue  padding  the  interstices  between  the  muscles,  lying  round  the  cervix 
uteri  and  spreading  out  beneath  the  Pelvic  Peritoneum. 

I.  The  Pelvic  Fascia  of  the  anatomist  is  carefully  described  in  the 
ordinary  systematic  and  dissecting-room  manuals,  to  which  the  student  is 
therefore  referred. 

IL  The  loose  connective  tissue  found  lying  subperitoneally,  surround- 
ing the  cervix  uteri  and  spreading  out  between  the  layers  of  the  broad 
ligament,  is  of  the  highest  importance  pathologically,  as  in  it  and  in  the 
pelvic  peritoneum  occur  those  inflammatory  exudations  so  common  in 
women.  Of  late  years  our  knowledge  of  the  disposition  of  this  tissue  has 
been  rendered  much  more  accurate,  and  accordingly  our  discrimination  of 
pelvic  inflammatory  attacks  made  much  more  precise. 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        45 

The  distribution  and  relations  of  the  pelvic  connective  tissue  may  be 
studied  in  various  ways.  The  most  valuable  information  is  obtained  by 
considering  sections  of  frozen  or  spirit-hardened  pelves.  This  gives  the 
precise  position  of  the  tissue,  its  amount,  and  distribution.  The  sections 
are  made  in  various  directions  :  antero-posteriorly,  in  the  middle  line 
(sagittal  mesial)  ;  antero-posteriorly,  at  the  junction  of  the  broad  liga- 
ments and  uterus  (lateral  sagittal)  ;  horizontally,  at  various  levels  ;  and 
finally,  coronally,  i.e.,  parallel  to  the  coronal  suture  and  dividing  the  pelvis 
into  anterior  and  posterior  portions.  Another  valuable  method  of  inves- 
tigation is  to  inject  air  beneath  the  peritoneum,  between  the  layers  of  the 
broad  ligament  and  at  other  points.  By  this  we  learn  the  varying  attach- 
ments of  the  pelvic  peritoneum  to  the  subjacent  tissue,  and  the  lines  of 
cleavage,  as  it  were,  of  the  pelvic  connective  tissue  along  which  pus  will 
burrow. 

Instead  of  air  we  may  inject  plaster  of  Paris  or  water  ;  plaster  of  Paris 
will  be  found  the  most  useful.  We  therefore  consider — 

a.  Results  obtained  by  section. 

b.  Results  obtained  by  the  injection  of  water,  air,  plaster  of  Paris. 

a.  Results  obtained  by  Section. 

1.  Vertical  Mesial  Section. — This  shows  a  large  amount  of  loose  tissue 
lying  between  the  posterior  aspect  of  the  symphysis  pubis  and  the  angle 
formed  by  the  urethra  and  anterior  wall  of  bladder — the  retro-pubic  fat 
deposit  (Hart).     It  is  a  matter  of  some  importance  to  note  its  shape  when 
the  bladder  is  empty  and  the  female  in  the  dorsal  posture.     It  is  then  dis- 
tinctly triangular.     Between  the  sacrum  and  rectum,  between  the  pos- 
terior wall  of  the  bladder  and  the  uterus,  and  between  the  supra-vaginal 
portion  of  the  cervix  and  posterior  vaginal  wall,  connective  tissue  in  com- 
paratively small  amount  is  distributed  (Figs.  34,  39).     Note  specially  that 
loose  tissue  separates  the  posterior  vaginal  wall  from  the  anterior  rectal 
wall  as  far  as  the  apex   of  the  perineal   body  where  they  are   closely 
blended  (Fig.  35)  ;  that  the  urethra  and  anterior  vaginal  wall  have  no 
such  loose  tissue  intervening,  i.e.,  are  closely  united ;  while,  as  already 
stated,  the  anterior  vaginal  wall  and  posterior  aspect  of  bladder  are  sepa- 
rated by  tissue. 

2.  Lateral  Sagittal  Section. — By  this  section  a  specially  valuable  view  is 
obtained.   Fig.  45  shows  an  accurate  drawing  of  such  a  section,  just  at  the 


46  MANUAL    OF    GYNECOLOGY. 

junction  of  the  uterus  and  broad  ligaments.  It  should  be  noted  that  the 
amount  of  retropubic  tissue  is  less  than  in  the  sagittal  mesial  one  ;  that  at 
the  junction  of  the  broad  ligaments  with  the  uterus  there  is  a  large  amount 
of  tissue  with  large  blood-vessels  ;  and  specially  that  the  finger  placed  in 
the  lateral  fornix  vaginae  touches  the  base  of  the  broad  ligament  there. 
This  fact  is  valuable  as  to  diagnosis.  On  section,  the  boundaries  of  the 


Fig.  45. 

Lateral  sagittal  section  of  pelvis  at  junction  of  broad  ligament  and  uterus,     a,  vagina  with  its  \vnlls 
separated  ;  6,  bladder ;  c,  symphysis ;  d,  broad  ligament ;  e,  ovary  ;  /,  Fallopian  tube. 

space  between  the  broad  ligaments  are  seen  ;  superiorly  the  cut  section  of 
the  Fallopian  tube,  anteriorly  and  posteriorly  the  peritoneum,  and  in- 
feriorly  the  vaginal  fornix.  The  assertion  by  Guerin  and  Le  Bee  as  to 
the  insignificance  of  the  tissue  here  is  not  borne  out. 

Sections  made  nearer  the  side  pelvic  wall  display  specially  the  lessen- 
ing tissue  between  the  layers  of  the  broad  ligaments  and  show  sections  of 
the  ovary. 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        47 

3.  Horizontal  sections  give  results  confirming  those  above  stated.  It  is 
unfortunate  that  no  good  sections  are  as  yet  published.  Pirogoff  gives 
several,  but  these  are  not  clearly  defined  in  their  connective  tissue  relations. 
Freund  has  published  an  admirable  description  of  his  preparations,  but  it 
is  to  be  regretted  that  he  has  not  figured  them.  The  most  valuable  sec- 
tions are  those  at  the  level  of  the  supravaginal  portion  of  the  cervix,  which 
show  the  tissue  lying  here  all  round  it.  At  Fig.  -4G  we  show  a  section 
from  lluedinger  where  the  retropubic  fat  and  ischiorectal  cavities  are  well 
shown. 

This  is  the  best  place  to  draw  special  attention   to  what  Yirchow  first 


, 


:    z.^^^:&///%^\ Vi^«ssgP-*i\\<vV^  ,v^4vC?£ 
,\  IS  VIS  ^^f(,^  '  ,%SS^S§%!^^ 

^E^^^fe^pi^v'o 


~-\->':' 


I  ransvcrso  section  or  female  pelvis  at  jilniiGof  hip-inint.1*  (Kui'iHiiiriT).     H,  <-»<T\\  ;  /*,  ischioroctal  fo-?,i; 


termed  the  parametric  tissue.  T.y  this  term  he  meant  the  loose  fatless 
tissue  (2  cm.  thick),  with  abundant  blood-vossels  mid  lymphatics,  sur- 
rounding "  the  lower  portion  of  the  uterus  and  the  upper  portion  of  the 
vagina  "  (Spiegelberg).  This  is  the  parametric  tissue  proper.  Some  ex- 
tend the  meaning  of  the  term  parametric  tissue  so  as  to  include  all  the 
connective  tissue  in  the  pelvis. 

('nrnrin]  Si'dlnn. — There  lias  been  published   no  fro/en   coronal  section 
of  the  pelvis  alone.     Fig.  17  and  1'late   II.    show  Kuedinger's  coronal  sec- 


48 


MANUAL    OF    GYNECOLOGY. 


tion  of  a  female  cadaver,  but  this  displays  little  of  the  pelvic  relations.. 
This  section  will,  however,  be  considered  afterwards. 

A  useful  diagram  of  a  coronal  section  of  the  pelvis  is  given  by  Luschkav 
It  shows  well  the  relations  of  the  cavity  of  the  pelvis  to  the  sub-peritoneal 


Fig.  47. 
Coronal  frozen  section  of  pelvis  (Ruedinger).    a,  fundus  uteri ;  b,  bladder ;  d,  labium  minus ;  e,  lahium  m;ijus. 

connective  tissue  and  the  ischiorectal   fossa  (Fig.  48).     These  Luschka, 
terms — 

(1.)  Cavum  pelvis  peritoneale  (Fig.  48,  a). 

(2.)       "          "      subperitoneale  (do.,  b). 

(3.)       "          "      subcutaneum  (do.,  c). 

According  to  him  the  ischiorectal  fossa  communicates  with  the  sub 
peritoneal  connective  tissue  by  means  of  minute  apertures. 

b.  Results  obtained  by  Injections  of  Water,  Air,  or  Plaster  of  Paris. 

The  best  summary  of  these  results  is  given  by  Bandl,  to  whom  on  this, 
point  we  are  indebted  for  much  valuable  information. 


AX  ATOMY"    OF    THE    FEMALE    PELVIC    ORGANS. 


49 


Konig  in  his  researches  employed  the  bodies  of  women  who  had  died 
a  short  time  after  labour  from  non-puerperal  diseases,  and  injected  air  or 
water.  The  following  briefly  are  his  results  :—(!.)  Water  injected  be- 
tween the  layers  of  the  broad  ligament  high  up  in  front  of  the  ovary  passed 
first  into  the  tissue  lying  at  the  highest  part  of  the  side  wall  of  the  true 
pelvis.  It  then  passed  into  the  tissue  of  the  iliac  fossa  lifting  up  the  peri- 
toneum, and  followed  the  course  of  the  psoas,  passing  only  slightly  into 
the  hollow  of  the  iliac  bone.  Lastly,  it  separated  the  peritoneum  from 


Fi«r.  48. 

Diagram  of  coronal  section  of  pelvis  (Lnschka).     a,  peritoneal  cavity :  6,  snbperitoneal  cavity  ;  c,  ischlo- 

rectal  fossa  ;  cZ,  uterus. 

the  anterior  abdominal  wall  for  some  little  distance  above  Poupart's  liga- 
ment, and  from  the  true  pelvis  below  it. 

(2.)  On  injection  beneath  the  base  of  the  broad  ligament  to  the  side 
and  in  front  of  the  isthmus,  the  deep  lateral  tissue  became  filled  first ; 
then  the  peritoneum  became  lifted  up  from  the  anterior  part  of  the  cervix 
uteri.  The  separation  passed  thence  first  to  the  tissue  near  the  bladder, 
and  ultimately  the  fluid  passed  along  the  round  ligament  to  the  inguinal 
ring.  There  it  separated  the  peritoneum  along  the  line  of  Poupart's  liga- 
ment and  passed  into  the  iliac  fossa. 
VOL.  I.— 4 


50  MANUAL    OF    GYM  ECOLOGY. 

(3.)  An  injection  at  the  posterior  part  of  the  base  of  the  broad  liga- 
ment filled  the  corresponding  tissue  round  Douglas'  space,  and  then 
passed  on  as  described  at  (1). 

Schlesinger  has  followed  out  these  results  in  more  elaborate  researches, 
which,  we  regret,  space  prevents  us  quoting. 

The  significance  of  these  investigations  will  be  referred  to  under  Pelvic 
Peritonitis  and  Pelvic  Cellulitis. 


CHAPTER  II. 

THE  POSITION  OF  THE  UTEBTJS  AND  ITS  ANNEXA,  AND  THE  RE- 
LATION OF  THE  SUPEBJACENT  VISCERA. 


LITERATURE. 

Braune—Op.  cit.  Claudius — On  the  Position  of  the  Uterus :  Med.  Times  and 
Gazette,  1865,  p.  5.  Grade — Beitrage  zur  Bestimmung  der  normalen  Lage 
der  gesunden  Gebarmutter :  Archiv.  f.  Gynakologie,  Bd.  I.,  S.  84.  Foster — A  Con- 
tribution to  the  Topographical  Anatomy  of  the  Uterus  and  its  Surroundings  : 
Am.  J.  of  Obst.,  XIII.,  p.  30.  JSasse— Beobachtungen  iiber  die  Lage  der  Einge- 
weide  im  weiblichen  Beckeneingange :  Archiv.  f.  Gynak.,  Band  VIII. ,  S.  402. 
Pirogoff—Qp.  cit.  Sappey—Op.  cit.  Scliroeder — Op.  cit.  Sdiultze— Zur  Kenntniss 
von  der  Lage  der  Eingeweide  im  weiblichen  Becken:  Archiv.  fur  Gynak.,  Bd.  IX., 
S.  262.  An  admirable  account  of  the  subject  will  be  found  in  Dr.  Van  de 
Warker's  articles  on  a  study  of  the  Normal  Movements  of  the  Unimpregnated 
Uterus :  N.  Y.  Medical  Journal,  XXI. ,  p.  337 ;  and  on  the  Normal  Position 
and  Movements  of  the  Unimpreguated  Uterus  :  Am.  J.  of  Obst.,  Vol.  XI.,  p.  314. 
The  literature  is  also  well  given  there  and  in  Foster's  paper. 

THE  amount  of  literature,  chiefly  French  and  German,  on  this  subject 
is  much  too  extensive  even  to  be  mentioned  here.  This  is  partly  due  to 
the  inherent  difficulty  of  accurate  clinical  observations,  to  the  erroneous 
opinions  advanced  by  many  eminent  anatomists,  and  to  arbitrary  demands 
as  to  the  normal  uterine  position  made  by  gynecologists  with  strong 
opinions  on  anteversion. 

Thus,  in  the  well  known  works  of  Braune,  Luschka,  Cruveilhier,  and 
Henle,  the  uterus  is  figured  from  actual  sections  as  normal  with  the 
fundus  in  the  hollow  of  the  sacrum,  i.e.,  retroposed.  Claudius  of 
Marburg,  also  an  anatomist,  is  uncompromising  on  this  point.  He  states, 
indeed,  that  the  uterus  is  normal  only  when,  with  its  broad  ligaments,  its 
posterior  surface  touches  the  sacrum  as  closely  as  the  lungs  do  the  ribs 
(Fig.  49).  Now,  all  gynecologists  agree,  from  clinical  observation,  that 
the  body  of  the  uterus  lies  over  on  the  bladder,  with  the  os  uteri  looking 
more  or  less  back.  This  divergence  of  opinion  is  extraordinary ;  and  it 


02  MANUAL    OF    GYN ECOLOGY. 

leads  to  this  interesting  practical  observation,  that  what  the  anatomist 
considers  a  uterus  normal  in  position,  the  gynecologist  believes  to  be 
abnormal.  That  is,  the  retroverted  uterus — considered  normal  in  cadavera 
by  the  anatomist — is,  when  found  in  the  living  woman,  replaced  by  the 
gynecologist  so  that  it  lies  with  its  body  over  the  bladder. 

There  can  be  no  doubt  that  the  uterus  lies  normally  to  the  front,  with 
its  anterior  surface  resting  on  the  bladder.  Great  refinement  is  exercised, 
quite  unnecessarily,  by  many  gynecologists  in  settling  what  they  believe 
to  be  the  exact  angle  which  the  long  axis  of  the  uterus  should  make  with 


Fig.  49. 

Transverse  section  of  polvis  in  line  of  pyriform  muscles  (Luschka).  The  peritoneum  has  been  remoTed 
on  the  right  side,  a,  3d  sacral  vertebra;  ft,  bladder;  c,  ureter;  d,  levator  nni ;  «,  rectum;/,  anterior 
layer  of  broad  ligament;  g  uterus  ;  A,  pyriform  muscle.  Note  that  here  the  uterus  is  retroverted,  and  the 
pouch  of  Douglas  without  intestine. 

the  horizon,  when  a  woman  is  in  the  erect  posture  ;  and  this  refinement 
has  been  greatly  stimulated  by  the  mechanical  treatment  of  what  is  known 
by  many  as  anteversion  of  the  uterus. 

In  treating  of  this  vexed  question  we  shall  consider — 

1.  The  normal  form  and  position  of  the  uterus. 

2.  The  local  divisions  of  the  pelvic  floor  peritoneum  as  viewed  through 
the  pelvic  brim,  and  the  position  of  the  uterus  and  its  annexa. 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.         53 

3.  The  physiological  changes  in  the  position  of  the  uterus. 

4.  The  relation  of  the  small  intestine  to  the  pelvic  floor  and  to  the 
uterus  and  its  annexa. 


THE    NORMAL    1'ORM    AND    POSITION    OF    THE    I'TKRUS. 

The  question  of  form  of  the  uterus  we  consider  only  in  the  limited 
aspect  of  the  angular  relation  of  the  long  axis  of  the  uterus  to  the  long 
axis  of  the  cervix.  These  are  not  in  the  same  straight  line  but.  when  the 
bladder  and  rectum  are  empty,  lie  at  an  obtuse  angle  of  varying  value. 


This  angle  is  much  less  in  nmltiparous  women  (Fig.  'J7i.  and  more 
marked  in  nullipanc  Fig.  50).  The  position  of  the  uterus,  with  emptv 
bladder  and  rectum,  is  such  that  it  lies  with  its  anterior  surf-ice  touching 
the  posterior  aspect  of  the  bladder,  no  intestine  intervening  :  the  os  extcr 
mini  uteri  looks  downwards  and  backwards;  and  the  uterus  is  slightly 
twisted  as  a  whole  on  its  long  axis,  so  that  the  uterine  end  of  the  right 
Fallopian  tube  is  nearer  the  symphy.sis  than  that  of  the  left.  \\  <  have 
expressly  said  with  bladder  and  rectum  empty.  According  to  Sel:ii.t/e. 
the  long  axis  of  the  uterus  is  nearly  parallel  to  the  liori/on.  This  is 


04  MANUAL    OF    GYNECOLOGY. 

probably  exaggerated,  as  Schultze's  researches  were  conducted  in  a  way 
that  certainly  anteverted  the  uterus  unduly  (Figs.  27  and  50).  Many 
authors  figure  the  uterus  nearly  vertical  to  the  horizon,  for  this  purpose 
distending  the  bladder  until  the  uterus  is  elevated  to  what  they  consider 
the  proper  angle  (Fig.  51).  It  is  needless  to  say  how  absurd  this  is. 
Kohlrausch's  diagram,  so  often  quoted  in  support  of  this  allegation,  really 


Section  of   pelvis,  showing   uterus  driven   back   by  distended  bladder  and  peritoneum  disturbed  (Kohl- 
rausch).     This  is  not  a  normal  condition  of  parts  by  emu  means. 

shows,  if  it  show  anything,  the  position  of  the  uterus  when  the  bladder  is 
well  distended.  The  student  should  note  this  point,  as  Kohlrausch's  sec- 
tion is  the  favorite  diagram  of  those  who  treat  as  pathological  what  is 
really  a  normal  uterus.  Fig.  52,  from  Pirogoff,  shows  a  frozen  section 
supporting  Schultze's  contention. 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


55 


It  is  important  to  know  how  results  as  to  the  uterine  position  have 
been  obtained.  The  chief  methods  are  as  follows  : 

(1.)  By  Frozen,  Spirit-hardened,  or  Chromic  Acid  Sections. — Results  ob- 
tained in  this  way  are  not  specially  valuable,  as  there  is  some  post-mortem 
change  in  the  uterine  position  not  yet  thoroughly  understood. 


Fig., 52. 

Section  of  female  cadaver  (Pirogoff ).    a,  vagina :  6,  uterus ;  c,  bladder.     Note  bladder  in  diastole,  uterus 
.  parallel  to  horizon,  and  shallow  dip  of  Douglas'  pouch. 

(2. )  By  the  Si-manual  Examination  of  the  Pelvic  Contents. — This  is  prob- 
ably the  best  method,  although  it  exaggerates  the  normal  anteversion  of 
the  uterus  in  a  way  that  will  be  readily  understood  when  the  chapter  on 
the  bi-manual  has  been  studied. 

(3.)  By  the  use  of  the  Sound,  or  by  a  more  elaborate  means  described 
by  Schultze.  Space  does  not  permit  of  a  full  description  of  the  latter, 
but  a  good  account  of  it  is  given  in  Foster's  paper. 


56 


MANUAL    OF    GYNECOLOGY. 


THE    LOCAL   DIVISIONS   OF     THE     PELVIC     FLOOR     PERITONEUM    AS     VIEWED    THROUGH 
THE  PELVIC   BRIM,    AND    THE    POSITION    OF   THE   UTERINE   ANNEXA. 

For  valuable  papers  and  sections  on  this  subject,  we  are  indebted  to 
Hasse  of  Breslau  and  Ruedinger  of  Munich  (Fig.  53  and  Plate  II.).     Hasse 


Fig.  53. 

Female  pelvis  and  contents  viewed  through  the  pelvic  brim  (Hasse).  c,  bladder :  77,  paravesical  pouch  ; 
w,  nterns ;  o,  ovary  ;  t,  Fallopian  tube  ;  d,  pouch  of  Douglas  ;  /,  lateral  pouch  of  Douglas  :  i  f>,  infundibulo 
pelvic  ligament ;  /  r,  round  ligament ;  p  u,  position  of  ureter ;  I  o,  ovarian  ligament;  r.  rectum  ;  c,  colon. 

froze  not  quite  thoroughly  a  female  cadaver  in  the  upright  posture,  cut 
through  the  abdomen  transversely,  and  then  lifted  out  the  softened  viscera 
until  the  pelvic  contents  were  exposed  undisturbed.  The  bladder  was 
moderately  distended. 

Fig.  53  shows  Hasse's  drawing.     The  fundus  of  the  uterus  lying  on 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        5< 

the  bladder  is  well  seen.  In  front  of  the  broad  ligament — of  which  the 
infundibulo  pelvic  ligament  is  the  only  portion  visible  in  Fig.  53 — we  have, 
on  each  side,  the  paravesical  pouch  of  the  peritoneum.  Behind  it  lies  the 
lateral  pouch  of  Douglas  ;  while  just  behind  the  uterus,  and  bounded  on 
each  side  by  the  utero-sacral  ligament,  is  the  pouch  of  Douglas  proper. 
The  Fallopian  tubes  lie  in  the  true  pelvis,  in  the  paravesical  pouch.  Each 
broad  ligament  sweeps  outwards  and  backwards  to  near  the  sacro-iliac 
synchondrosis  of  its  own  side.  The  position  of  the  ureter  is  well  indi- 
cated. 

According  to  Hasse  the  long  axis  of  both  ovaries  runs  outwards  and 
forwards,  forming,  with  the  transverse  axis  of  the  uterus,  an  angle  open  to 


Fig.  54. 

Position  of  funduB  uteri  and  lie  of  ovaries.     Bladder  distended  (Schultze). 

the  front.  Part  of  each  ovary  (the  half)  projects  above  the  plane  of  the 
pelvic  brim.  Schultze,  on  the  other  hand,  figures  the  ovaries  as  having 
their  long  axes  almost  antero-posterior  (Fig.  54). 


THE    PHYSIOLOGICAL   CHANGES    IN    THE   POSITION    OF    THE    UTEBUS. 

The  mobility  of  the  uterus  is  one  of  its  most  characteristic  features. 
With  every  movement  of  respiration,  in  singing,  walking,  and  in  all  vio- 
lent movements,  the  uterine  position  is  changed.  Dr.  Van  de  Warker 
has  studied,  in  a  valuable  paper,  the  influences  bringing  about  these 
changes  in  position  ;  this  may  be  consulted  for  details  of  the  method  of 
investigation  and  results  obtained. 


58  MANUAL    OF    GYNECOLOGY. 

Of  the  greatest  importance  is  the  effect  of  the  distended  bladder  on 
the  uterine  position.  As  the  bladder  fills,  the  uterus  becomes  retroposed 
to  an  extent  shown  at  Figs.  51  and  54.  The  intestines  are  forced  out  of 
the  upper  part  of  Douglas'  pouch,  and  the  height  of  the  peritoneal  reflec- 
tion from  the  anterior  abdominal  wall  is  considerably  increased.  All 


Fig.  55. 

Position  of  uterus.    A,  when  bladder  and  rectum  empty ;  B,  C,  D,  according  to  distention  of  bladder  (Van 

de  Warker). 

these  points  are  well  illustrated  by  Fig.  44  from  Pirogoff.  As  the  urine 
is  evacuated,  the  uterus  passes  forward  to  its  normal  anteverted  condition 
and  the  intestines  pass  back  into  Douglas'  pouch.  Probably,  undue  dis- 
tention of  the  bladder  leads  to  permanent  retroversion  in  some  cases, 
especially  if  the  uterus  be  gravid.  Kectal  distention  displaces  the  uterus 
forwards  and  to  the  right  side. 


PLATE  11 


PLATE  II.-  CORONAL  SECTION  OF  FROZEN  FEMALE  CADAVER 
(JtUEDINGER), 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        59 

THE     RELATION     OF     THE    SMALL    INTESTINE    TO    THE   PELVIC     FLOOR     AND     TO     THE 
UTERUS    WITH    ITS    ANNEXA. 

The  small  intestine  lies  resting  on  the  uterus,  ovaries,  Fallopian  tubes, 
and  broad  ligaments.  There  is  no  small  intestine  in  the  vesico-uterine 
pouch.  When  the  bladder  is  empty  and  the  unimpregnated  uterus  to  the 
front,  there  is  small  intestine  in  Douglas'  pouch  except  at  its  very  lowest  part. 
The  pouch  of  Douglas  becomes  emptied  of  intestine  as  the  bladder  dis- 
tends, and  has  no  intestine  in  it  when  the  uterus  is  retroverted.  Many 
authors  assert  that  there  is  never  small  intestine  in  Douglas'  pouch.  This 
opinion  is  undoubtedly  wrong,  as  any  one  can  satisfy  himself  by  studying 
sections.  Often  Douglas'  pouch  contains  serum,  and  this  displaces  the 
intestine.  Figures  35,  39,  44  bear  out  these  opinions  ;  Fig.  47  and  Plate 
n.  should  be  carefully  studied  as  illustrating  the  position  of  the  super- 
jacent  intestines.  The  paravesical  pouch  probably  contains  intestine 
when  the  uterus  lies  to  the  front,  and  certainly  contains  it  when  the 
uterus  is  retroposed.  Occasionally  the  omentum  may  interpose  between 
the  small  intestine  and  the  pelvic  viscera. 

To  sum  up  briefly  : — 

a.  The  uterus  and  bladder  behave  practically  as  one  organ  qua  position 
(i.e.,  they  move  together),  when  the  uterus  is  to  the  front. 

b.  The  exact  angle  which  the  uterus  makes  with  the  horizon  cannot  be 
fixed,  and  knowledge  on  this  point  is  not  necessary. 

c.  The  uterus  lies  normally  to  the  front,  but  has  a  range  of  mobility 
indicated  in  Fig.  55.     The  posterior  lip  of  the  cervix  is  1.5  to  3  cm.  above 
the  tip  of  the  coccyx.    By  digital  pressure  the  uterus  can  be  elevated  about 
4  cm.  (1£  in.). 


CHAPTER  III. 

THE   STBUCTURAL  ANATOMY  OF   THE  FEMALE    PELVIC   FLOOR. 
THE  PELVIC  FLOOR  PROJECTION. 

LITERATURE. 

STRUCTURAL  ANATOMY.  Hart — The  Structural  Anatomy  of  the  Female  Pelvic 
Floor :  Edinburgh,  1881. 

PELVIC  FLOOR  PROJECTION.  Foster — Op.  cit.  Schroeder—Op.  cit.  Noch  ein  Wort, 
iiber  die  normale  Lage  und  die  Lageveriinderungen  der  Gebarmutter  :  Arch.  f. 
Gynak.,  Bd.  IX.,  S.  68.  Schul  se—Op.  cit.  Simpson  and  Hart — The  Relation  of 
the  Abdominal  and  Pelvic  Organs  in  the  Female  :  VV.  and  A.  K.  Johnston,  Edin- 
burgh and  London,  1881. 

THE  STRUCTURAL  ANATOMY  OF  THE  FEMALE  PELVIC1  FLOOR. 

HITHERTO  we  have  regarded  the  pelvic  floor  in  detail  as  made  up  of  bladder, 
vaginal  walls,  rectum,  connective  tissue,  and  peritoneum.  In  this  chapter 
we  purpose  considering  it  in  its  structural  aspect.  In  its  formation,  the 
following  functions  have  been  provided  for.  As  compared  Avith  the  floor 
of  the  male  pelvis,  the  female  pelvic  floor  differs  in  having  in  it  the  cleft 
known  as  the  vagina.  Then,  further,  women  have  to  undergo  parturition 
in  which  the  child  is  born  through  the  vagina,  which  is  then  greatly  dis- 
tended. At  the  same  time  a  woman  has  resting  on  her  pelvic  floor  the 
same  abdominal  viscera  as  the  male,  and  her  pelvic  floor  is  also  subjected 
to  the  same  strain  from  intra-abdominal  pressure.  Thus  we  have  to  ex- 
plain how  the  female  pelvkrfloor  has  been  constructed  so  as  to  allow  of 
parturition  and  yet  remain  strong  enough  to  resist  ordinary  intra-abdom- 
inal pressure.  The  question  is  a  structural  or  architectural  one.  We  study 
it  in  this  present  chapter  just  as  we  would  study  the  structure  of  a  box  or 
chair. 

In  order  to  understand  this  question,  we  must  look  at  the  pelvic  floor 
in  sagittal  mesial  section  as  at  Fig.  40.  In  this  view  we  see  the  pelvic  floor 
or  diaphragm  stretching  from  symphysis  pubis  to  sacrum.  The  anus  is  to 
be  imagined  closed  as  in  life.  The  first  thing  to  note  is  the  vagina,  which 


PLATE  1 


SURFACE  VIEW  OF  ABDOMEX  A>'D  THORAX;    THE  SECTION  IS  SEEN  AT 
PLATE  II. 


1.   Right  Hypochondriac. 
4.  Right  Lumbar. 
7.  Right  Iliac. 


2.  Epigastric. 
5.  Umbilical. 
8-  Hypogastric. 


3.  Left  Hypochondriac. 
6.  Left  Liimbnr. 
9.  Left  Iliac. 


Tlte  uppermost  Une  indicates  the  position  ofttir  Diaphragm. 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS.  61 

is  seen  as  a  cleft  running  upwards  in  the  pelvic  floor  from  hymen  to  cer- 
vix uteri.  Its  walls  are  in  close  apposition  (vide  Figs,  passim).  They  are 
often  erroneously  represented  apart ;  in  order,  as  it  were,  to  let  the  student 
see  the  vagina.  .This  is  wrong,  however.  It  is  no  more  necessary  to  figure 
the  vaginal  walls  always  apart,  than  it  would  be  always  to  sketch  a  man 
with  his  mouth  open  to  render  it  visible.  The  first  idea  one  gets  on  look- 
ing at  such  a  section  is  that,  owing  to  the  apposition  of  the  vaginal  walls, 
the  pelvic  floor  in  the  woman  is  unbroken  ;  and  that  the  vaginal  cleft,  the 
introduction  of  which  does  weaken  the  floor  somewhat,  cuts  the  floor  not 
perpendicularly  to  the  horizon  but  obliquely  at  an  angle  of  about  60°. 

The  pelvic  floor,  as  seen  in  this  section,  is  made  up  of  two  segments 
which  are  known  as  the  pubic  and  sacral  segments.  It  is  of  importance  to 
define  these  exactly. 

The  Pubic  Segment  is  made  up  of  loose  tissue,  viz. ,  bladder,  urethra, 
anterior  vaginal  wall,  and  bladder  peritoneum.  It  is  attached  in  front  to 
the  symphysis  pubis.  This  attachment  is  a  loose  one  ;  the  bladder  and 
urethra,  meeting  one  another  at  right  angles,  are  separated  from  the  pubis 
by  the  pyramidal  deposit  of  loose  fat  already  described  as  the  retropubic 
fat  deposit.  Note  specially  that  the  retropubic  fat  deposit  as  seen  in  this 
section — that  of  a  woman  in  the  dorsal  or  the  erect  posture — is  triangular  ; 
and  that  the  peritoneum  passes  from  the  anterior  abdominal  wall  on  to  the 
fundus  of  the  bladder,  just  a  little  above  the  top  of  the  symphysis. 

The  Sacral  Segment  is  attached  to  the  coccyx  and  sacrum  ;  it  consists 
of  rectum,  perineum,  and  strong  tendinous  and  muscular  tissue.  The  in- 
ferior portion  of  this  segment,  the  perineum,  lies  about  1£  inch  from  the 
symphysis. 

So  far  we  have  described  the  mesial  attachments  of  the  segments.  The 
pubic  segment,  however,  is  also  attached  on  each  side  to  the  anterior  bony 
pelvic  wall,  while  the  sacral  segment  is  attached  in  a  like  manner  to  the 
posterior  bony  pelvic  wall.  Finally,  these  two  segments  blend  with  one 
another  on  the  right  and  left  sides  of  the  vagina. 

The  two  segments  are  thus  anatomically  contrasted  :— 

The  pubic  segment  is  made  up  of  loose  (issue  and  is  loosely  attached  lo  the 
pubic  symphysis  ;  the  sacral  segment  is  made  up  of  strong  tissue  and  is  firmly 
dovetailed  into  the  sacrum  and  coccyx. 

They  are  further  contrasted  functionally: — 

The  pubic  segment  is  drawn  up  during  labonr  ;  the  sacral  segment  is 
driven  down. 


62  MANUAL    OF    GYNECOLOGY. 

The  proof  for  this  functional  contrast  is  too  elaborate  to  be  given  here 
and  will  be  found  given  in  detail  in  Dr.  Hart's  atlas.  It  may  be  briefly 
explained,  however,  that  during  labour  the  pubic  and  sacral  segments  act 
like  two  folding  doors.  Uterine  action  pulls  up  the  pubic  segment,  and 
drives  the  child  down  against  the  sacral  one.  This  action  is  analogous  to 


Fig.  56. 

Pelvic  floor  differentiated  in  parturition  (Braune).    The  pubic  segment  is  drawn  up  and  the  sacral  one 
driven  down.    Note  position  of  bladder  and  its  peritoneum :  for  lettered  description,  see  Fig.  43. 

the  way  one  passes  out  through  two  folding  doors,  where  he  pulls  the  one 
door  towards  him  and  pushes  the  other  from  him. 

As  the  result  of  this  elevation  of  the  pubic  segment,  the  bladder  is 
drawn  above  the  pubis  and  its  peritoneum  stripped  off  (Fig.  56). 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


63 


In  addition  to  the  retropubic  fat  deposit,  it  should  be  noted  that — 
a.  The  posterior  wall  of  the  bladder  is  loosely  attached  to  the  ante- 
rior vaginal  wall ; 

b. '  The  urethra  and  anterior  vaginal  wall  are  closely  blended  ; 
c.  The  posterior  vaginal  wall  and  anterior  rectal  wall  are  loosely  con- 
nected, as  far  down  as  the  apex  of  the  perineal  body  (Fig.  35). 
There  are  three  lines  of  cleavage  in  the  pelvic  floor  (Fig.  57). 


Fig.  57. 

Lines  of  cleavage  indicated  by  dotted  lines.    From  before  backwards  they  are— 1,  physiological ;  2,  path- 
ological ;  3,  bi-manual  (Hart). 

1.  Physiological,  between  the  vaginal  walls  ;  all  in  front  of  this  line 

is  drawn  upwards  in  parturition. 

2.  Pathological,  between  the  posterior  vaginal  and  anterior  rectal 

walls  ;  all  in  front  of  this  is  displaced  downwards  in  Prolapsus 
uteri. 

3.  Bi-manual,  between  the  anterior  and  posterior  rectal  walls  ;  all  in 

front  of  this  is  displaced  on  bi-manual  recto-vaginal  examina- 
tion. 

From  the  structural  arrangement  of  the  pelvic  floor,  it  results,  as  will 
be  shown  more  fully  afterwards,  that— 

1.  There  is  a  definite  opening  up  of  the  pelvic  floor  during  parturi- 


(54  MANUAL    OF    GYNECOLOGT. 

tion  and  when  a  woman  assumes  the  genupectoral  posture  with 

the  vaginal  orifice  opened  up  ; 
2.  There   are  produced  definite  displacements  of   the  pelvic  floor 

when  the  various  specular  means  of  exploring  it  are  employed 

and  under  excessive  intra-abdomiual  pressure  or  hypertrophic 

growths  of  the  cervix. 

The  nomenclature  employed  should  be  noted.  It  is  better  to  speak  of 
the  pubic  segment  being  separated  from  the  sacral  one  than  of  the  vaginal 
walls  being  apart.  The  vaginal  walls  are  not  special  structures.  The  an- 
terior vaginal  wall  is  the  posterior  boundary  of  the  pubic  segment ;  the  pos- 
terior vaginal  wall  is  the  anterior  boundary  of  the  sacral  segment.  Thus 
they  are  analogous  to  the  edges  of  two  folding  doors.  We  shall  refer  to 
this  again  under  prolapsus  uteri  and  examination  with  the  Sims  speculum. 
The  question  of  the  support  of  the  uterus  is  still  disputed.  The  broad 
and  round  ligaments  have  nothing  to  do  with  its  support ;  they  are  only 
useful  as  giving  fixed  points  for  the  contracting  uterine  muscle  during 
parturition.  The  utero-sacral  ligaments,  however,  probably  help  in  sup- 
porting the  uterus. 

Many  allege  most  erroneously  that  the  vagina  supports  the  uterus,  as 
if  the  vagina  were  a  special  structure.  The  chief  support  is  the  compact 
unbroken  pelvic  floor,  on  which  the  uterus  rests  just  as  one  sits  on  a  chair. 
It  is  the  whole  pelvic  floor  that  supports  the  uterus  and  viscera,  not  the 
perineum  alone.  The  perineum  is  only  a  small  though  strong  part  of  the 
sacral  segment. 

The  various  components  of  the  pubic  segment  are  definitely  displaced 
in  its  movements.  Thus  the  retropubic  fat  is — 

1.  Behind  the  pubis  in  the  non-partmient  female  (Fig.  52)  ; 

2.  Above  it  in  the  parturient  female  (Fig.  56)  ; 

3.  Below  it  in  prolapsus  uteri  ; 

4.  Below  it  in  the  extra  pelvic  floor  projection  of  pregnancy  ; 

5.  Partially  above  the  symphysis  in  the  genupectoral  posture  (Fig. 

G5). 
The  peritoneum  is — 

1.  Reflected  on  to  the  top  of  the  empty  bladder  in  the  nou  parturient 

female ; 

2.  Stripped  off  the  bladder  during  parturition  ; 

3.  Reflected  on  to  fund  us  of  empty  bladder,  at  a  higher  level  above 

symphysis,  in  the  genu-pectoral  posture. 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


65 


Thus  the  peritoneum  over  the  bladder  is  movable ;  the  peritoneum  over 
the  sacral  segment  is  fixed. 

It  will  now  be  seen  that  the  structural  problem  stated  at  the  begin- 
ning of  the  chapter  is  solved  thus.  The  sacral  segment,  strengthened  at 
its  tip  by  the  perineum,  is  the  supporting  one  ;  it  holds  the  pubic  seg- 
ment, just  as  the  hand  at  Fig.  58  holds  the  pessary.  The  anterior  mar- 
gin of  the  sacral  segment  stops  short  at  the  pubis  by  about  1£  inch,  and 
this  interspace  is  filled  up  by  the  pubic  segment  Intra-abdominal  pres- 


Fig.  58. 

Hand  holding  pessary. 

/ 

sure  presses  the  pubic  segment  against  the  oblique  sacral  one  which 
closes  the  pelvic  outlet,  therefore,  like  a  valve  ;  excessive  intra-abdominal 
pressure  displaces,  in  prolapsus  uteri,  a  definite  part  of  the  pelvic  floor  in 
front  of  the  anterior  rectal  wall. 


PELVIC  FLOOR  PROJECTION. 

By  this  is  understood  the  amount  of  projection  of  the  pelvic  floor,  in 
sagittal  mesial  section,  beyond  the  straight  line  joining  the  tip  of  the  coccyx 
and  the  subpubic  ligament — conjugate  of  outlet  (Fig.  59). 

Definite  results  have  not  as  yet  been  obtained,  but  this  is  one  special 
reason  why  attention  should  be  directed  to  it. 

Schroeder  measured  the  conjugate  at  the  outlet  with  callipers ;  and 
VOL.  L— 5 


66 


MANUAL    OF    GYNECOLOGY, 


then  passed  a  measuring  line  from  the  coccyx  to  the  apex  of  the  pubic 
arch,  the  tape  following  the  curve  of  the  pelvic  floor.  The  subjoined  table 
gives  some  of  his  results. 


Average  of  the  pregnant  women 

"          "       gynecological  patients . 
"          "       nulliparse 


Distance  from  tip  of  coccyx  to  lower 
border  ot  symphysis. 


By  tape  measure.         By  callipers. 


c.m. 
13.35 
12.6 
13.2 


9.15 

8.27 

8.75 


Schroecler's  deduction  is  that  the  average  projection  of  the  pelvic  floor 
beyond  the  plane  of  the  pelvic  outlet  is  4.1  c.in.  There  is  no  doubt  that 
this  is  an  excessive  average,  as  may  be  seen  by  consulting  the  pelvic  sec- 
tion in  Schroeder's  manual. 

F.  P.  Foster  of  New  York  has  written  ably  on  this  subject  and  made  a 


Fig.  59. 

Diagram  to  show  whnt  is  meant  by  pelvic  floor  projection,      a,  p  =  conjugate  of  outlet.    '  A  perpendicular 
bisecting  a,  p,  and  cutting  the  arc  gives  the  greatest  pelvic  floor  projection  (P.  P.  Foster). 

large  series  of  observations.  Fig.  60  shows  the  callipers  he  employed. 
An  end  of  each  limb  (a  and  b)  is  placed  on  the  tip  of  the  coccyx  and  lower 
border  of  the  symphysis  pubis.  The  horizontal  bar  between  these  limbs 
is  graduated  in  c.m.,  and  the  limb  (a)  glides  along  it  in  a  groove.  A 
movable  upright  (c),  also  graduated,  has  its  upper  point  placed  against 
the  most  projecting  part  of  the  pelvic  floor.  If  now  the  whole  apparatus 
be  removed  and  laid  flat  on  a  sheet  of  paper,  the  conjugate  and  amount  of 
projection  can  be  read  off  at  once.  Greater  accuracy  is  ensured  by  noting, 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS.  G7 

before  removing  the  apparatus,  the  point  on  the  transverse  bar  at  which 
the  upright  (c)  stands  as  well  as  the  reading  which  it  gives. 


Fig.  60. 
Callipers  for  measuring  pelvic  floor  projection  (Foster). 

Foster's  average  (2.5  c.ni.)  of  the  pelvic  floor  projection  is  less  than 


\  Fig.  01. 

Diafrmm  of  polvic  floor  projection  and  position  of  uterus,  nio.lific'1  from  Footer. 

Schroeder's.      He  placed  his  patient   scmiprone,    however;    a  position  in 
which  the  pelvic  floor  projection  is  slightly  diminished.      Fig.  (Jl   shows 


68  MANUAL    OF    GYNECOLOGY. 

Foster's  diagram  of  pelvic  floor  projection.  The  uterus  has  been  more 
anteverted  than  in  Foster's  original  drawing. 

Measurements  made  on  frozen  sections  cannot  be  trusted.  Schroeder 
has  justified  his  average  by  such  measurements,  but  has  taken  no  account 
of  the  existence  of  pregnancy  in  some  of  the  cases. 

We  might  tentatively  advance  the  following  statements : — 

(1.)  The  pelvic  floor  projection  is  over-estimated  by  Schroeder; 

(2.)  Foster's  and  Schultze's  average  is  nearer  the  mark  ; 

(3.)  The  retropubic  fat  gives  a  rough  index  of  the  position  of  the  pubic 
segment  (Figs.  41,  42,  50) ; 

(4.)  The  pelvic  floor  projection  is  increased  by  advanced  and  even  by 
early  pregnancy  (Braune's  Plates). 

The  whole  enquiry  needs  further  investigation  in  order  to  settle  also 
other  points,  among  which  we  may  mention  the  relation  of  the  vagina  to 
the  pelvic  outlet  and  the  varying  amount  of  pelvic  floor  projection  in  dif- 
ferent postures. 


CHAPTER  IV. 

THE    BLOOD-VESSELS,    LYMPHATICS,  AND   NERVES   OF   THE  PEL- 
VIS :  DEVELOPMENT  OF  PELVIC  ORGANS. 


BLOOD-VESSELS  Ilyrtl — Die  Corrosions-anatomic  imil  inre  Kruebnisse,  W.  Brau- 
niiiller:  Wien,  187;].  Henle — Op.  cit.  Klein  und  Smith's  Atlas.  l.uxchka, 
(Jnain,  Sappey,  Sara  ye — Op.  cit. 

LYMIMIATICS.  Bviirycry  and  Jacob — Truite  Complct  de  i' Anatomic  de  I'llomine  : 
Paris,  1S)<).  Champonnicrc — Lymphatiques  Uti  rines  et  Lymphangite  Uterine: 
Bull,  de  la  Soc.  Med.  des  Hupitaux  de  Paris,  Vol.  VII.  Khin — The  Anatomy  of 
the  Lymphatic  System  :  London,  1871!.  Lc.  lice — On.  cit.  G.  Leopold — Die  Lym- 
phgefiissc  des  nornialen  nicht  schwangeren  Uterus:  Archiv.  fiir  Gynilk.,  Bd. 
VI.,  S.  1.  Tr.  T.  Jjixk — Puerperal  Fever  :  International  Congress  Tr.,  Philad., 
1ST  7.  Sappcif,  Sai-aye — Op.  cit. 

NKHVKS.  — 7'.  Sific  Ihck— The  Nerves  of  the  Uterus  :  Phil.  Tr.,  IS  1C.  7-^^rr?-— Dia- 
grams of  the  Nerves  of  the  Human  Body:  J.  and  A.  Churchill,  London,  1S72. 
^"Tunkenhaitfter — Die  Nerven  der  Geburmutter  und  ilire  Endiirung  in  den  glatten 
Muskelfasern :  Jena,  181)7.  R.  Lee  --The  Anatomy  of  the  Xcrves  of  the  Uterus: 
London,  Bailliere,  1S-11.  Tiedcmaiin — Talnilie  Xervurum  1'teri  :  Heidelberg, 
1822. 

DEVELOPMENT  OF  THE  PELVIC  OK<;AXS.  I''on!is — The  Develoi)mcnt  of  the  Ova,  and 
the  Structure  of  the  Ovary  in  Man  and  the  other  Mammalia  :  Tr.  R.  S.,  Kdin., 
Vol.  XXVII.  Klein  and  Smilli,  (Jiniin.  Turner — Op.  cit. 

BLOOD-VESSELS. 

WE  consider  (1.)  the  iirtcrial  supply  of  the  uterus,  ovary,  Fallopian  tube, 
vagina,  bladder,  and  rectum;  (2.)  that  of  the  perineal  region:  (•$. )  the 
venous  distribution. 

(1.)  Arterial  SHJ>I>[I/  to  Utcrux,  (leant,  ''/<"• — The  ovarian  art<'nj  of  each 
side  (corresponding  to  the  spermatic  of  the  male)  is  a  branch  of  the 
abdominal  aorta.  Its  relations  when  in  the  abdomen  do  not  concern  us 
here.  In  the  pelvis  it  passes  between  the  layers  of  the  broad  ligament, 
running  tortuously  towards  the  upper  angle  of  the  uterus.  Near  this  it 


70  MANUAL    OF    GYNECOLOGY. 

divides  into  two  branches.  The  upper  supplies  the  fundus  uteri ;  the 
lower  anastomoses  at  the  side  of  the  uterus  with  the  uterine  artery  (Plate 
m.,c,  d). 

The  Ovarian  Artery  gives  off — 

Branches  to  the  ampulla  of  the  Fallopian  tube  (Plate  in.,  a'  a'). 

Branches  to  the  isthmus  (6'), 

Numerous  branches  to  the  ovary  (cr  c'  c'), 

Branch  to  the  round  ligament  (6). 

The  Uterine  Artery  (Plate  HI.,  e)  springs  from  the  anterior  division  of 
the  internal  iliac  and  passes  downwards  and  inwards  towards  the  cervix 
uteri.  It  then  passes  upwards  between  the  layers  of  the  broad  ligament 
by  the  side  of  the  uterus,  in  an  exceedingly  tortuous  manner  well  shown 
in  Plate  IH.,  to  anastomose  with  the  lower  branch  of  the  ovarian. 
Branches  pass  from  it  into  the  substance  of  the  uterus  ;  these  are  the 
curling  arteries  of  the  uterus.  The  Vaginal  arteries  (g,  g,  g)  usually  spring 
immediately  from  the  anterior  division  of  the  internal  iliac  artery,  but 
sometimes  arise  from  the  uterine  or  middle  hsemorrhoidal.  A  special 
branch  of  the  uterine  artery  to  the  cervix  joins  with  its  fellow  at  the  isth- 
mus to  form  the  circular  artery,  and  with  those  of  the  vagina  to  form  the 
azygos  artery  of  the  vagina  (h,  h).  The  vaginal  arteries  anastomose  freely 
with  those  of  the  opposite  side.  Plate  HI.,  from  Hyrtl,  illustrates  beauti- 
fully the  free  anastomosis  of  branches  of  the  aorta  with  the  ovarian,  uter- 
ine, and  vaginal  arteries.  It  should  be  noted  that,  in  an  operation  for 
removal  of  uterus,  ligature  of  the  broad  ligament  controls  all  hemorrhage. 

From  the  same  anterior  division  of  the  internal  iliac,  proceeds  the 
blood  supply  to  the  bladder  and  rectum. 

(2.)  Arterial  Supply  to  the  perineal  region.— This  comes  from  the  in- 
ternal pudic.  The  superficial  perineal  branch  supplies  the  labia ;  the 
artery  to  the  bulb  supplies  the  bulbus  vaginae  ;  the  terminal  branches  go 
to  the  clitoris. 

(3.)  Venous  Supply. — The  venous  supply  of  the  pelvis  is  very  abundant, 
and  exists  in  the  form  of  numerous  plexuses  freely  communicating  with 
one  another.  The  veins  are  unprovided  with  valves.  Hemorrhage  from 
a  wound  is  therefore  often  exceedingly  profuse,  especially  during  preg- 
nancy when  the  whole  pelvic  vascular  system  is  hypertrophied. 

The  following  is  a  summary  of  the  main  facts  as  to  the  venous  supply 
of  the  female  pelvis. 
...  The  vesical  plexus  lies  external  to  the  muscular  coat  of  the  bladder. 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


71 


The  hcemorrhoidal  plexus  lies  below  the  mucous  membrane  of  the  lower 
part  of  the  rectum. 

The  veins  of  the  labia  correspond  in  distribution  to  the  arteries,  and 
those  from  the  outermost  parts  drain  into  the  pudic  which  opens  into  the 


common  iliac  vein.  Large  veins  from  the  labia  minora  open  into  the  pars 
intermedia  of  the  bulb. 

The  veins  from  the  glans  and  corpora  clitoridis  pass  into  the  dorsal 
vein  of  the  clitoris,  which  communicates  with  the  vesical  plexus. 

The  veins  of  the  bulb  pass  into  the  vaginal  plexus. 

The  vaginal  plexuses — one  outside  the  muscular  coat  and  one  in  the 


72  MANUAL    OF    GYNECOLOGT. 

submucous  tissue— are  most  abundant  at  the  lower  part  of  the  vagina, 
communicate  with  the  hsemorrhoidal  and  vesical  plexuses,  and  open  into 
the  internal  iliac  vein. 

The  uterine  plexus  is  very  abundant,  as  is  well  shown  in  one  of  Hyrtl's 
plates ;  it  ultimately  opens  into  the  ovarian  veins  (Fig.  62),  which  pass, 
on  the  right  side  to  the  inferior  vena  cava,  on  the  left  to  the  left  renal 
vein.  The  veins  are  small,  lie  in  the  outer  muscular  coat,  and  run  longi- 
tudinally ;  they  open  into  large  sinuses  in  the  middle  layer  of  the  coat,  with 
which  the  capillary  vessels  communicate. 

The  ovarian  plexus,  otherwise  known  as  the  pampiniforin  plexus,  lies 
between  the  folds  of  the  broad  ligament  and  communicates  with  the  uter- 
ine plexus  (Fig.  62).  Some  apply  this  term  to  all  the  veins  in  the  broad 
ligament.  The  ovarian  plexus  opens  into  the  inferior  vena  cava. 

Beneath  the  peritoneum  and  between  the  layers  of  the  broad  ligaments 
are  vast  venous  plexuses.  Knowledge  on  this  point  is  of  the  highest  im- 
portance in  relation  to  pelvic  hsematocele. 

The  vesical,  hremorrhoidal  and  vaginal  plexuses,  with  the  pudic  veins, 
open  into  the  internal  iliac  vein  which  opens  into  the  inferior  vena  cava. 

From  the  hsemorrhoidal  plexus,  the  superior  hremorrhoidal  vein  passes 
into  the  portal  system  ;  and  thus  we  get  a  communication  between  the 
pelvic  and  portal  venous  systems. 

LYMPHATICS. 

Under  this  we  take  up — 

a.  The  Lymphatic  Glands  ; 

b.  The  Lymphatic  Vessels. 

a.  The  Lymphatic  Glands. — These  are  (1.)  the  inguinal  glands,  which 
lie  parallel  to  and  just  below  Poupart's  ligament ;  and  (2.)  the  pelvic 
(jlands.  These  latter  consist  of  (a)  a  gland  at  the  isthmus  uteri  (Cham- 
ponniere)  ;  (b)  hypogastric  glands,  which  lie  subperitoneally  in  the  space 
between  the  external  and  internal  iliac  vessels ;  (c)  sacral,  on  the  lateral 
aspect  of  the  anterior  surface  of  the  sacrum  and  in  the  mesorectum  ;  and 
(d)  a  gland  or  collection  of  small  glands  at  the  obturator  foramen — the 
obturator  gland  of  Guerin.  These  all  pour  into  the  lumbar  glands,  which 
lie  in  front  of  the  lumbar  vertebrae  and  discharge  into  the  thoracic  duct. 

6.  The  Lymphatic  Vessels.  (1.)  Of  External  Genitals. — Numerous  ves- 
sels form  a  network  on  the  internal  aspect  of  the  labia  majora,  over  the 
labia  minora  and  round  the  vaginal  and  urethral  orifices,  vestibule  and 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        73 

clitoris  ;  all  of  these  open  into  the  inguinal  glands.  From  this  arrange- 
ment, the  enlargement  of  the  inguinal  glands  in  syphilis  and  vulvar  cancer 
is  intelligible.  The  lymphatics  of  the  lower  fourth  of  the  vagina  also  open 
into  these  glands. 

(2.)  Of  Vagina  (upper  three-fourths)  and  Cervix  Uteri. — The  lymphatics 
from  these  open  into  the  hypogastric  glands.  So  far  we  have  followed 
Sappey's  description. 

Le  Bee  asserts  that  the  lymphatics  of  the  vagina  pour  into  a  series  of 
trunks  at  the  level  of  the  isthmus  uteri,  and  that  those  of  the  cervix  join 
them  ;  and  that  the  conjoined  lymphatics  then  pass  below  the  base  of  the 
broad  ligament  to  the  obturator  ganglion,  from  which  vessels  communi- 
cate with  others  from  the  thigh  and  even  from  the  epigastrium. 

The  relation  between  lymphatics  and  glands  is  as  follows  : — 

(a)  Those  of  the  external  genitals  pass  into  the  inguinal  glands. 

(6)  The  lymphatics  of  the  vagina  and  cervix  pass  to  the  hypogastric 
glands  (Sappey).  According  to  Le  Bee,  they  pass  to  the  obturator  gland. 

(3.)  Of  Uterus. — The  lymphatics  of  the  body  of  the  uterus  pass 
through  the  broad  ligaments,  and,  along  with  those  from  the  ovary  and 
Fallopian  tube,  enter  the  lumbar  glands.  If  Le  Bee  be  right,  the  lym- 
phatics from  the  cervix  pass  below  the  broad  ligament,  and  those  from  the 
uterus  along  the  upper  part  of  the  same. 

Leopold,  who  has  investigated  the  lymphatics  in  the  unimpregnated 
uterus,  considers  "the  mucous  membrane  of  the  uterus  as  a  lymphatic 
surface  which  contains  no  special  lymphatic  vessels,  but  consists  of  lymph 
sinuses  covered  with  endothelium."  "The  lymph  passes  from  the  lym- 
phatic spaces  of  the  mucous  membrane,  through  the  mucous  membrane 
hollows,  into  the  lymph  spaces  and  vessels  of  the  muscular  coat,  surrounds 
here  all  the  bundles  up  to  the  serous  covering,  and  flows  into  the  larger 
vessels  ^which  enter  the  broad  ligament  in  the  neighborhood  of  the  ves- 
sels." (Loc.  cit.,  S.  31.) 

These  are  matters  not  of  mere  anatomical  detail,  but  of  the  very  high- 
est pathological  and  practical  importance.  The  richness  of  lymphatic 
supply  to  the  vagina,  cervix,  and  uterus  explains  the  extraordinary  rapid- 
ity with  which  septic  matter  spreads  through  the  body,  and  the  extreme 
danger  which  may  attend  even  an  insignificant  lesion  of  the  internal  geni- 
tal organs,  when  septic  matter  is  present  and  is  absorbed.  We  may  re- 
mark here  that  septic  matter  will  of  course  follow  the  lymphatic  routes 
already  laid  down.  It  should  not  be  forgotten,  however,  that  the  bacteria 


74  MANUAL    OF    GYNECOLOGY. 

passing  along  the  lymphatic  vessels  may  penetrate  them,  pass  into  the 
peritoneal  cavity,  and  thence  spread  through  the  diaphragm  to  set  up  the 
.pleurisy  and  pericarditis  so  common  in  septicaemia  (Lusk).  Thorough 
comprehension  of  lymphatic  distribution  and  knowledge  of  the  evil  effects 
of  septic  matter  are  of  the  first  importance  to  the  student. 

The  lymphatics  of  the  Rectum  lie  in  two  layers  (mucous  and  muscular), 
and  open  into  the  glands  of  the  mesorectum  or  into  the  sacral  glands. 

The  stomata  of  the  peritoneum  of  the  pelvis  communicate  with  lymph 
capillaries  lying  in  the  subendothelial  tissue. 

NERVES. 

These  are  (a)  Spinal,  (6)  Sympathetic. 

(a)  Spinal. — The  following  is  the  nervous  supply  of  the  pelvic  mus- 
cles : — 

Levator  and  Sphincter  Ani  are  supplied  by  inferior  hsemorrhoidal  branch 
of  pudic,  4th  and  5th  sacral,  and  coccygeal  nerves  ; 

Coccygeus,  by  4th  and  5th  sacral  and  coccygeal  nerves  ; 

Muscles  of  Perineum  and  Clitoris,  by  the  branches  of  pudic  nerve. 

(b)  Sympathetic. — The  hypogastric  plexus,  which  lies  between  the  com- 
mon iliac  arteries,  gives  off  branches  which,  reinforced  by  branches  from 
the  lumbar  and  sacral  ganglia  and  sacral  nerves,  form  the  inferior  hypo- 
gastric  plexuses — one  on  each  side  of  the  vagina.     From  these,  filaments 
proceed  to  the  vagina,  uterus,  Fallopian  tube,  and  ovary. 

The  terminations  of  the  nerves  in  the  muscular  layers  of  the  uterus 
have  been  studied  by  Frankenhaiiser,  who  figures  them  passing  to  the 
nuclei  of  the  unstriped  muscle.  Those  entering  the  mucous  membrane 
are  said  to  end  in  ganglia.  Numerous  end  bulbs  have  been  found  in  the 
clitoris  and  vagina. 

DEVELOPMENT  OF  PELVIC  ORGANS. 

The  following  is  a  very  brief  summary  : — 

The  Wolffian  bodies  appear  in  the  foetus  about  the  third  and  fourth 
week.  They  fulfil  the  function  of  kidneys  until  the  second  month,  and 
then  wither. 

The  Fallopian  tubes,  uterus  and  vagina  are  derived  from  the  Ducts  of 
Miiller.  These  appear  on  the  anterior  aspect  of  the  Wolffian  bodies. 


ANATOMY  OF  THE  FEMALE  PELVIC  OKGANS.        VO 

Their  lower  portions  coalesce  to  form  the  uterus  and  vagina  ;  while,  above, 
they  remain  separate,  as  the  Fallopian  tubes. 

The  ovary  first  appears  as  a  thickening  on  the  Wolffian  bodies.  It  is 
made  up  of  interstitial  tissue  projecting  from  them  and  covered  by  epithe- 
lium— the  germ  epithelium.  According  to  Foulis,  the  ova  are  developed 
from  the  latter  ;  the  cells  of  the  membrana  granulosa  are  formed  from  the 
connective  corpuscles  of  the  interstitial  tissue.  Waldeyer  believes  that  the 
ova  and  the  cells  of  the  membrana  granulosa  both  originate  from  the  germ 
epithelium  ;  and  in  this  Balfour  agrees  with  him  (vide  chap,  on  Ovarian 
Tumours). 

The  parovarium  arises  as  a  small  distinct  structure  at  the  summit  of 
each  Wolffian  body.  It  persists  in  the  female  (Fig.  22).  In  the  male  it 
forms  the  epididyinis. 

The  clitoris  develops  from  a  small  eminence  at  the  front  of  the  uro- 
genital  sinus. 

Up  to  the  second  month  of  foetal  life  the  genital  urinary  and  intestinal 
ducts  open  into  the  cloaca,  which  then  becomes  divided  by  a  transverse 
partition  into  a  posterior  anal,  and  anterior  urogenital  sinus.  The  vestibule 
in  the  adult  female  is  simply  the  lower  part  of  the  latter  sinus. 

The  labia  minora  results  from  the  non-coalescence  of  folds  analogous  to 
those  which,  by  their  coalescence,  form  in  the  male  the  corpus  spongiosum 
urethrse. 

The  labia  majora  are  two  folds  which  remain  separate  in  the  female  but 
coalesce  in  the  male  to  form  the  scrotum. 

The  two  bulbi  vagince  are  homologous  to  the  corpus  spongiosum 
urethrae. 

For  fuller  details  see  Turner  and  Quain. 


CHAPTER  V. 

PHYSICS  OF  THE   ABDOMEN  AND  PELVIS,  WITH  SPECIAL  REFER- 
ENCE TO  THE  SEMIPRONE  AND  GENU-PECTORAL  POSTURES. 

LITERATURE. 

W.  Braune — Die  Obersohenkelvene  des  Menschen  in  Anatomischer  und  Klinischer 
Beziehung:  Leip7,ig,  Veifc  and  Co.,  1871.  J.  M.  Duncan — On  the  Retentive 
Power  of  the  Abdomen :  Researches  in  Obstetrics,  p.  409.  Hart — The  Structural 
Anatomy  of  the  Female  Pelvic  Floor.  Simpson  and  Hart — The  Relations  of  the 
Abdominal  and  Pelvic  Organs  in  the  Female.  Scliatz — Beitrage  zur  physiolo- 
gischen  geburtskunde  :  Archiv.  fiir  Gynak.,  Bd.  IV.,  S.  191.  Einfluss  der  Lehre 
vom  inlraabdominalen  Drucke  auf  die  Gynakologie:  Archiv.  fiir  Gynak.,  Bd.  V., 
S.  227.  Van  de  Warker — A  Study  of  the  Normal  Movements  of  the  Unimpreg- 
nated  Uterus :  N.  Y.  Med.  Jour.,  Vol.  XXI.,  page  337. 

IN  this  chapter  it  is  proposed  to  give  a  brief  sketch  of  a  subject  of  the 
highest  importance  but  still  in  its  infancy.  The  resume  must  be  restricted, 
from  want  of  spacfc,  to  certain  practical  points  ;  we  therefore  consider 
here — 

1.  The  effect  of  intra-abdominal  pressure  on  the  female  pelvic  floor ; 

2.  The  results  brought  about  by  change  of  posture,  especially  by  the  genu- 
pectoral  posture  ; 

3.  The  effect  on   uterine  position  of  digital  pressure  in  the   vaginal 
fornices. 

THE   EFFECT   OF   INTRA-ABDOMINAL    PRESSURE    ON    THE    FEMALE    PELVIC    FLOOR. 

We  suppose  the  woman  to  be  in  the  upright  posture.  For  simplicity 
the  pelvic  floor  is  considered  as  being  under  fluid  pressure.  Fig.  63  shows 
the  effect  of  this  on  the  pelvic  floor  segments.  The  fluid  pressure  acts  at 
right  angles  to  the  limiting  surface  which,  in  this  case,  is  the  pelvic  peri- 
toneum. Thus,  if  the  perpendiculars  be  counted,  starting  from  the  sym- 
physis,  it  can  readily  be  seen  that  the  first  three  will  press  the  pubic  seg- 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        77 

ineiit  against  the  symphysis  ;  that  the  fourth  and  fifth  will  do  this  also, 
but  will  further  have  a  resultant  tending  to  drive  the  pubic  past  the  sacral 
segment ;  that  the  sixth  and  seventh  will,  directly,  tend  to  do  this  ;  and 
that  the  others  will  drive  it  partly  past  tl»e  sacral  segment,  and  partly 
against  it.  From  want  of  rigidity  in  the  pubic  segment,  this  driving 
down  tendency  is  partly  lost.  Thus  the  effect  of  ordinary  intra-abdominal 
pressure  is  to  press  the  pubic  against  the  sacral  segment.  Extra  intra- 
abdominal  pressure  displaces  downwards  a  definite  portion  of  the  pelvic 
floor — viz.,  all  lying  in  front  of  the  anterior  rectal  wall.  There  is  in  the 


Fig.  63. 

Diagram  to  illustrate  effect  of  intra-abdominal  pressure  on  the  segments  of  the  pelvic  floor  (Hart),  o, 
uterus  pathologically  ante-flexed ;  &,  bladder;  c,  retropubic  fat;  d,  labium  ma  jus  ;  «,  symphysis;/,  peri- 
nea! body ;  g,  rectum. 

pelvic  floor  a  definite  line  of  cleavage  at  which  it  yields,  which  line  runs 
between  the  anterior  rectal  and  posterior  vaginal  walls  (see  p.  63). 

This  definite  downward  displacement  causes  the  lesion  known  as  pro- 
lapsus uteri. 

From  this  we  see  that  the  female  pelvic  floor  is  not  equally  strong 
throughout.  It  would  be,  were  the  sacral  segment  prolonged  and  attached 
to  the  symphysis  pubis.  But  then  parturition  would  have  been  an  impos- 
sibility. It  has  been  constructed  not  only  qud  intra-abdominal  pressure, 
but  also  qud  parturition. 


78  MANUAL    OF    GYNECOLOGY. 

THE   RESULTS    BROUGHT    ABOUT   BY   CHANGE   OF    POSTURE,    ESPECIALLY    BY    THE 
GENU-PECTORAL   POSTURE. 

The  abdominal  walls,  along  with  the  viscera  bounded  by  them,  are 
often  spoken  of  as  the  abdominal  cavity  with  its  contained  viscera.  We 
must,  however,  keep  in  mind  that  this  cavity  is  always  perfectly  full. 
There  is  never  any  vacuum  in  it.  The  viscera  are  always  in  apposition, 
with  only  a  little  fluid  as  a  film  separating  them.  The  abdominal  walls 
are  yielding,  and  any  tendency  to  a  vacuum  is  counteracted  by  atmos- 
pheric pressure  on  the  walls.  The  vertical  height  'of  the  abdomen  is  too 
small  to  admit  of  a  Torricellian  vacuum  ;  and  therefore  it  is  no  more 
wonderful  that  we  have  no  vacuum  in  the  abdominal  cavity,  than  that 
there  is  no  vacuum  in  an  ordinary  test-tube  filled  with  water  and  with  its 


Ffe  64. 

Outline  of  female  figure  in  genu-pectoral  posture.  The  dotted  line  indicates  the  contour  when  the  vagi, 
nal  orifice  is  unopened ;  the  continuous  line,  the  change  in  contour  after  air  is  admitted  into  the  vagina 
(Simpson  and  Hart). 

open  end  immersed.  There  would  be  a  vacuum  if  the  test-tube  were 
above  33  feet  long  ;  and  so  would  there  be  in  a  race  of  giants,  the  vertical 
height  of  whose  abdominal  cavity  was  such  that  the  column  of  contained 
viscera  could  not  be  counterpoised  by  the  atmospheric  pressure.  In  no 
posture  a  woman  can  assume  is  there  ever  a  vacuum  in  the  abdominal 
cavity.  However  high  the  pelvis  be,  though  the  woman  stand  on  her 
head,  the  small  intestines  still  touch  the  uterus  as  they  do  in  Fig.  47  and 
Plate  II.  The  abdominal  walls  and  viscera  enclosed  by  them  behave, 
therefore,  like  a  plastic  viscous  fluid — like  so  much  thick  gum  or  treacle. 

When  a  woman  is  in  the  upright  posture,  the  viscera  bulge  above  the 
symphysis  pubis,  more  or  less,  according  to  her  development.  Plate 
I,  shows  this  bulging  in  a  well-formed  nude  female  ;  the  bulging  is 
excessive  if  the  woman  is  fat.  Just  below  the  sternum,  the  antero- 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS.  79 

posterior  diameter  of  the  abdomen  is  lessened.  The  pelvic  floor  is 
convex  as  seen  from  without,  i.  e.,  the  pelvic  floor  projection  is  well 
marked.  Atmospheric  pressure  is  acting  equally  all  over  the  abdominal 
and  pelvic  surfaces  ;  but  the  pelvic  floor,  bearing  the  weight  of  the  vis- 
cera, bulges  more  than  the  other  boundaries  of  the  abdomen.  A  fluid 
contained  in  a  bag  suspended  from  a  fixed  point  is  pyriform,  with  the 
bulb  nearer  the  earth.  This  shape  is  due  to  the  weight  of  the  fluid. 

If  a  woman  be  made  to  assume  the  posture  known  as  the  genu-pectoral 
(better  genu-facial),  the  bulge  of  the  viscera  is  at  the  sternum.  The  fol- 
lowing points  should  be  noted  in  regard  to  this  posture  (Fig.  64). 

1.  The  antero-posterior  diameter  of  the  abdominal  cavity  is  increased 
at  the  sternum. 

2.  It  is  diminished  above  the  pubis  and  in  the  iliac  fossae. 

3.  The  pelvic  floor  projection  is  diminished. 

4.  The  pubic  and  sacral  segments  are  still  in  contact,  and  the  abdomi- 
nal viscera  always  in  contact  with  the  uterus  and  one  another. 

Let  us  now  contrast  these  postures. 

Upright  posture  (Plate  L).  Genu-pectoral  posture  (Fig.  64). 

1.  Greatest  antero-posterior    (a-p)     1.  Greatest   antero-posterior   diam- 

diameter    of    abdomen    just  eter  at  sternum, 

above  pubis. 

2.  Least  a-p  diameter  at  sternum.  2.  Least  a-p  diameter  below  pubis. 

3.  Pelvic    floor    projection    at    its  3.  Pelvic    floor    projection    dimin- 

maximum.  ished. 

4.  Pelvic  floor  segments  in  contact.      4.  Pelvic  floor  segments  in  contact. 

In  the  latter  posture,  on  inspection  of  the  genitals  the  labia  can  be 
seen  to  be  furrowed  and  the  skin  over  the  ischiorectal  fossa  slightly  hol- 
lowed. If  now  the  labia  majora  and  minora  be  separated  and  the  four- 
chette  lifted  up,  no  further  change  as  yet  takes  place :  but  when  the 
hymen  is  opened  up,  air  passes  into  the  vagina  (often  with  a  distinct  hiss) 
and  the  vaginal  walls  become  separated,  enclosing  a  somewhat  large  cavity. 
The  bulge  at  the  sternum  is  now  slightly  increased,  while  that  above  the 
pubis  is  diminished  (see  Fig.  64).  It  is  only  when  the  anatomical  entrance 
of  the  vagina  (the  hymeneal  orifice)  is  opened  up,  that  the  vagina  distends 
with  air. 

It  has  been  shown  by  Drs.  Russell  Simpson  and  D.  Berry  Hart,  that 
the  segments  of  the  pelvic  floor  separate  from  each  other  when  a  woman 


80  MANUAL    OF    GYNECOLOGY. 

assumes  the  genu-pectoral  posture  and  the  hymeneal  orifice  is  opened. 
The  pubic  segment  passes  down  with  the  viscera ;  the  sacral  segment 
remains  behind,  recoiling  slightly  upwards.  Thus  functionally,  the  pubic 
segment  in  visceral,  the  sacral  one  is  vertebral. 

They  have  shown  further  that  there  is  quite  a  definite  displacement  of 
the  pubic  segment  constituents,  viz.  : — 

a.  The  empty  bladder  is  partly  above  the  pubis  ; 

b.  The  peritoneum  passes  from  abdominal  wall  to   symphysis,  at  a 
point  1£  inch  above  the  latter  ; 

c.  The  retropubic  fat  is  partly  above  and  partly  below  the  top  of  the 
symphysis.     We  may  now  once  more  contrast  these  postures. 

Genii  pectoral    posture   (with  vagina 
Upright  posture  (Plate  L).  distended  by  air)  (Fig.  65). 

1.  Pubic  and    sacral    segments   in     1.  Pubic  and  sacral  segments  sepa- 

apposition  and  vagina  a  slit.  rated  and  vaginal  walls  bound- 

ing a  cavity. 

2.  Retropubic  fat  behind  pubis.  2.  Eetropubic  fat  partly  above  pu- 

bis. 

3.  Empty  bladder  behind  pubis.  3.  Empty  bladder  partly  above  pu- 

bis. 

4.  Peritoneum  passes  from  anterior    4.  Peritoneum  passes  from  anterior 

abdominal  wall    to   fundus  of  abdominal  wall  to   fundus  of 

empty     bladder,     immediately  empty     bladder,    1£     inches 

above  symphysis.  above  symphysis. 

5.  Urethra  and  bladder  meet  at  a  5.  Urethra  and   bladder   almost  in 

right  angle.  same  line. 

The  reason  why  the  pubic  segment  passes  downwards  when  the  vaginal 
orifice  is  opened,  is  that  atmospheric  pressure  now  acts  on  the  vaginal  as- 
pect of  the  pubic  segment  (with  its  weak  mesial  attachment  to  the  pubis) 
and  drives  it  further  down.  As  the  result  of  this  posture,  changes  take 
place  in  the  length  and  direction  of  the  vaginal  walls  and  in  the  position 
of  the  uterus.  These  are  briefly  : — 

1.   Vagina. — (a.)  Both  walls  elongate. 

(b. )  The  anterior  follows  the  direction  of  the  posterior  as- 
pect of  the  symphysis  ;  the  posterior,  the  curve  of 
the  sacrum. 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS. 


81 


2.  Uterus, — (a.)  The  normally  placed  uterus  passes  nearer  the  sacrum 
and  nearer  the  thoracic  diaphragm. 

(6.)  The  retroverted  uterus,  fixed  or  unfixed,  becomes 
more  retroverted. 

(c.)  The  retroverted  unfixed  uterus  does  not  become  re- 
placed so  as  to  lie  anteverted. 


Tit:.  65. 

Pelvis  in  frozen  section  of  cadaver  in  genn  pectoral  posture.  4,  anus;  P,  perineum  ;  R,  rectum;  I", 
vagina  ;  u,  urethra ;  S,  bladder ;  S,  symphysis  ;  /,  retropubic  fat ;  O,  retroverted  uterus ;  p  p,  peritoneum. 
Between  the  small  intestine  and  peritoneum  is  fatty  omentum  (Simpson  and  Hart). 

The  results  given  have  been  obtained  as  follows  : — 

a.  By  observation  on  living  patients,  aided  by  silhouettes  of  the  out- 
lines of  the  nude  body  in  the  upright  and  genu-pectoral  postures  ; 

6.  By  study  of  frozen  sections  of  the  female  pelvis,  and  especially  by 
study  of  a  frozen  section  of  a  cadaver  placed  in  the  genu-pectoral  posture. 

For  further  details  on  this  subject  Simpson  and  Hart's  atlas  may  be 

consulted. 

VOL.  I.— 6 


82 


MANUAL    OF    GYNECOLOGY. 


An  important  practical  result  follows  from  these  observations.  The 
vagina  dilates  or,  more  properly,  the  segments  of  the  pelvic  floor  separate,  ex- 
posing their  free  margins — the  vaginal  walls — when  a  patient  assumes  the 
genu-pectoral  posture  and  the  hymeneal  orifice  is  opened  so  as  to  admit  air. 
If  a  patient  be  so  placed  opposite  a  good  light  and  the  sacral  segment  be 
hooked  up,  a  complete  view  of  the  vaginal  walls  and  cervix  is  obtained. 
The  same  results  can  be  got  by  placing  the  patient  in  the  posture  known 
as  the  semiprone.  On  this  last  fact  is  based  the  use  of  the  vaginal  specu- 
lum known  as  Sims'  Duckbill  speculum  (v.  Chap.  X.). 


THE  EFFECT  ON  UTERINE  POSITION  OF   DIGITAL  PRESSURE  IN    THE  VAGINAL    FORNICES. 

This  is  a  subject  of  great  practical  importance. 

If,  when  a  patient  is  lying  on  her  left  side,  the  index  finger  of  the  ex- 
aminer's right  hand  is  passed  into  the  vagina  as  far  as  the  posterior  fornix, 


Fig.  66. 
Anteversion  being  produced  by  digital  pressure  in  posterior  fornix. 

and  pressure  made  there  in  the  direction  of  the  antero  posterior  axis  of 
the  fornix,  the  following  results  may  be  noted  : — 

(1.)  The  posterior  vaginal  wall  is  elongated,  the  cervix  drawn  back, 
and  the  uterus,  if  anteverted,  becomes  more  so  (Fig.  66). 


ANATOMY    OF   THE    FEMALE    PELVIC    ORGANS.  83 

(2.)  If  the  uterus  is  retroflexed,  the  flexion  is  not  remedied.  Should 
the  fundus  be  fixed,  the  retroflexion  is  increased  as  the  cervix  is  drawn 
back  while  the  fundus  remains. 

Similarly,  if  pressure  be  made  in  the  anterior  fornix : — 

(1.)  The  uterus  becomes  elevated  and  slightly  rotated  backwards, 
because  the  cervix  is  pulled  forwards  (Fig.  67). 

(2.)  If  the  uterus  is  anteflexed,  the  flexion  is  not  diminished. 

By  pressure  in  these  fornices,  therefore,  we  only  act  on  the  cervix, 


Fig.  67. 
Retroversion  of  uterus  produced  by  digital  pressure  in  anterior  fornii. 

unless  the  uterus  is  very  much  retroverted  or  anteverted.     The  body  of 
the  uterus  is  acted  on  only  indirectly,  through  its  union  with  the  cervix. 

Consequently,  no  vaginal  pessary  can  undo  the  flexion  of  a  retroflexed 
or  anteflexed  uterus. 

RELATION   OF   POSTURE   TO    EXAMINATION   AND   TREATMENT. 

We  have  already  mentioned  several  postures  as  being  the  proper  ones 
for  certain  manipulations ;  and  we  here  sum  up  briefly  what  it  is  of  use  to 
know  in  regard  to  these. 

The  side-lateral,  where  the  patient  lies  on  her  side  in  the  ordinary  way, 
is  convenient  for  vaginal  examination  ;  passage  of  Fergusson's,  Neuge- 
bauer's,  or  Cusco's  speculum  ;  passage  of  the  sound  and  catheter. 


Si  MANUAL    OF    GYKECOLOGY. 

The  dorsal  posture  is  imperative  for  abdominal  examination  and  the 
bi-manual. 

The  semiprone  is  the  best  posture  for  the  passage  of  Sims'  speculum  ; 
vesico-vaginal  fistula  operation. 

The  lithotomy  posture  is  specially  valuable  for  operations  on  the  peri- 
neum, vaginal  walls,  cervix  and  uterus. 

The  genu-pectoral  posture  is  useful  for  replacement  of  the  retroverted 
uterus. 


CHAPTER  VI. 
MENSTRUATION  AND  OVULATION. 

LITERATURE. 

Beigel — Die  Krankheiten  des  weiblichen  Geschlechtes  :  F.  Enke,  Stuttgart,  1875. 
Dalton — Report  on  the  Corpus  Luteum :  Am.  Gyn.  Tr.,  Vol.  II.,  p.  11  :  Physiology, 
6th  edition,  J.  and  A.  Churchill,  1876.  Engdmann — The  Mucous  Membrane  of 
the  Uterus,  with  especial  reference  to  the  Development  and  Structure  of  the  De- 
cidua :  Am.  J.  of  Obst.,  Vol.  VIII.,  p.  30.  Prey's  Histology— Barker's  Tr.,  1874. 
Kinkead — Med.  Press,  September  14,  1881.  Kundrat — Untersuchungen  iiber  die 
Uterusschleimhaut :  Strieker's  Jahrbuch,  1873.  (Kundrat  and  Engelmann  were 
co-workers.)  Leopold — Studien  uber  die  Dterusschleimhaut  wahrend  Menstrua- 
tion, Schwangerschaft  und  Wochenbett :  Archiv.  fiir  Gynak.,  Bd.  XI.,  S.  1091. 
Loewenhardt — Die  Berechnung  und  die  Dauer  der  Schwangerschaft :  Archiv.  fiir 
Gynak.,  Bd.  III.,  S.  456.  Moncke — Die  Uterusschleimhaut  in  den  verschiedenen 
Altersperioden  und  znr  Zeit  der  Menstruation:  Ztschr.  fiir  Geburtshiilfe  und 
Gynak.,  VII.  Band,  1  Heft,  1881.  Underhill—Note  on  the  Uterine  Mucous  Mem- 
brane of  a  Woman  who  died  immediately  after  Menstruation  :  Ed.  Med.  J. ,  1875. 
Simpson,  A.  Russell — Emmenologia  ;  Contribution  to  Obstetrics  and  Gynecology  : 
Edinburgh,  A.  and  C.  Black.  Lawson  Tait — Br.  Med.  Journ.,  June  4, 1881.  Wil- 
liams— On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,  and  its  Periodi- 
cal Changes:  London  Obst.  Jour.,  VoL  II.,  p.  681. 

THE  subject  of  Menstruation  is  not  as  yet  well  known,  and  on  many  points 
eminent  and  trustworthy  observers  are  at  variance.  So  far  as  our  present 
knowledge  goes,  the  following  is  a  brief  resume. 

PRELIMINARY   CONSIDERATIONS. 

Definition. — A  periodical  flow  of  blood  from  the  uterine  cavity,  with 
shedding  of  the  superficial  layers  of  its  mucous  membrane,  accompanying 
the  discharge  of  an  ovum  from  the  ovary,  occurring  in  properly  developed 
women  between  the  ages  of  14  and  44,  and  interrupted  by  uterogestation 
and  lactation. 

Period  of  its  Onset. — Menstruation  begins,  in  this  country,  usually  at 


86  MANUAL    OF    GYNECOLOGY. 

the  age  of  13  to  15  (puberty).  It  may  be  delayed  to  16,  17,  or  20  ;  but 
this  is  unusual.  Its  onset  is  earlier  in  warm  countries,  later  in  cold 
ones  ;  earlier  in  delicately  nurtured  girls. 

Period  of  its  Cessation. — With  the  interruptions  of  pregnancy  and  lac- 
tation, it  continues  in  healthy  women  until  the  age  of  44  to  50.  The 
period  of  its  final  cessation  is  known  as  the  menopause.  As  a  general 
rule  the  menopause  is  early  when  menstruation  has  begun  early,  and  vice 
versa. 

GENERAL  PHENOMENA  OF  MENSTKUATION. 

Ctianges  at  Puberty. — At  this  period  of  life,  when  the  girl  becomes  the 
woman,  we  find  certain  well  marked  general  changes  occurring.  The 
bust  and  mons  veneris  develop,  and  the  whole  contour  of  the  body  becomes 
more  rounded  and  attractive ;  hair  appears  on  the  genitals.  The  romp- 
ing carriage  of  the  girl  becomes  subdued,  and  greater  shyness  character- 
ises her  conduct  to  the  opposite  sex. 

Phenomena  Premonitory  to  each  Menstrual  Flow. — There  is  usually  a 
feeling  of  weight  in  the  pelvis  and  increase  of  sexual  inclination.  Many 
women,  however,  have  very  little  uneasiness  during  the  whole  flow  ;  while 
others  are  always  considerably  distressed — this  distress  being  still  outside 
the  boundary  of  actual  disease. 

Periodicity  and  Duration  of  Discharge. — When  once  established  it 
recurs  with  great  regularity  every  28  days  (in— 71  p.  c.),  30  days  (in— 14 
p.  c.),  21  days  (in— 12  p.  c.),  or  27  days  (in-f  1  p.  c.).  We  speak  there- 
fore of  the  21  day  type  and  so  on.  It  lasts  for  a  number  of  days,  varying 
from  2  to  8.  If  below  2  or  above  8  it  is  abnormal ;  but  of  course  other 
points  besides  mere  duration  must  be  taken  into  account. 

LOCAL   PHENOMENA. 

Three  periods  are  distinguished  : 

1.  Invasion, 

2.  Persistence, 

3.  Decline. 

1.  Invasion. — Discharge  pale. 

2.  Persistence. — Discharge  bright  red,  non-coagulable  from  its  admix- 
ture with  mucus.     It" consists  microscopically  of  epithelium  from  vaginal, 


ANATOMY  OF  THE  FEMALE  PELVIC  ORGANS.        87 

cervical,  and  uterine  cavities  ;  mucous  globules  ;  compound  granular  cor- 
puscles, and  red  and  white  blood  corpuscles. 

3.  Decline. — Discharge  lessens  in  amount  and  becomes  lighter  in 
color. 

The  total  quantity  varies  from  2  to  8  ounces. 

Thus  far  we  have  related  facts  fairly  well  ascertained  and  not  much 
disputed.  We  now  enter  on  more  debateable  ground,  in  consider- 
ing— 

I.  Ovulation  ; 

II.  The  Corpus  Luteum  ; 

in.  Source  of  discharge  and  changes  in  the  uterine  mucous  mem- 
brane. 

I.  Ovulation. — So  far  as  our  present  knowledge  goes,  ovulation  forms 
the  starting-point  of  the  process  of  menstruation.  We  have  already 
considered  the  structure  and  development  of  the  ovary,  and  now  de- 
scribe 

The  Changes  in  the  Ovary  at  each  Menstrual  Period. — A  Graafian  follicle 
enlarges  and  moves  nearer  the  surface.  Probably  this  produces,  through 
a  nervous  mechanism,  a  hypersemia  of  the  whole  pelvic  contents — perito- 
neum, connective  tissue,  uterus,  ovaries,  Fallopian  tubes,  and  vagina.  It  is 
alleged,  as  yet  on  insufficient  grounds,  that  the  fimbriated  end  of  the 
Fallopian  tube  grasps  the  ovary,  and  that  the  ovum  from  the  ruptured 
Graafian  follicle  passes  into  it  and  along  the  tube  to  the  uterine  cavity. 
Professor  Kinkead  of  Galway  has  recently  advanced  another  explanation. 
He  points  out  that,  between  the  fimbriated  end  of  the  Fallopian  tube  and 
the  ovary,  we  have  the  ovarian  fimbria  (Fig.  22)  forming  a  groove  which 
is  converted  into  a  tube  by  the  surrounding  viscera ;  and  that  conse- 
quently we  have  capillary  action  towards  the  uterus.  This  will  lead  the 
ovum  into  the  Fallopian  tube.  However  it  may  reach  the  Fallopian  tube 
and  uterus,  its  further  development  depends  on  its  fertilization  or  non- 
fertilization.  In  the  latter  case  it  passes  off  unnoticed  in  the  menstrual 
discharge  ;  in  the  former  it  develops  into  the  foetus. 

H.  The  Corpus  Luteum. — After  the  rupture  of  the  Graafian  follicle,  we 
get  its  cavity  filled  up  by  the  structure  known  as  the  corpus  luteum. 

The  corpus  luteum  consists  of  a  vascular  framework,  with  a  yellow 
pigmentary  and  cellular  substance.  It  varies  according  as  pregnancy 
does  or  does  not  follow  its  formation.  The  difference  is  well  given  in 
Dalton's  table,  which  we  subjoin. 


88 


MANUAL    OF    GYNECOLOGY. 


End  of  three  weeks . . 


One  month. . 
Two  months. 


Four  montha 


Six   months 


Nine  months 


Corpus  Luteum  of  Men- 
struation. 


12  by  13  mm.  in  di- 
ameter ;  central  clot 
reddish,  convoluted 
wall  pale. 

Smaller  ;  convoluted 
wall  bright  yellow  ; 
clot  still  reddish. 

Insignificant  cicatrix. 


Absent     or   unnotice 
able. 


Absent.. 


Absent. 


Corpus  Luteum  of  Pregnancy. 


Larger ;  convoluted  wall 
bright  yellow  ;  clot  still 
reddish. 

12  by  22  millimetres  in  di- 
ameter ;  convoluted  wall 
bright  yellow  ;  clot  per- 
fectly decolorized. 

18  by  22  millimetres  in 
diameter  ;  clot  pale  and 
fibrinous ;  convoluted 
wall  dull  yellow. 

Still  as  large  as  at  the  end 
of  the  second  month  ; 
clot  fibrinous ;  convo- 
luted wall  paler. 

10  by  13  millimetres  in  di- 
ameter ;  central  clot  con- 
verted into  a  radiating 
cicatrix ;  external  wall 
tolerably  thick  and  con- 
voluted, but  without  any 
bright  yellow  color. 


HI.  Source  of  Discharge  and  Changes  in  the  Uterine  Mucous  Membrane. 
— All  observers  are  agreed  that  the  mucous  membrane  of  the  uterine 
cavity  is  the  source  of  the  discharge,  i.e.,  that  it  comes  from  the  area 
limited  by  the  uterine  ends  of  the  Fallopian  tube  and  the  os  internum. 

Now  begins  the  divergence. 

(1.)  Williams  holds  that  "  uterine  contraction  drives  the  blood  from 
the  muscular  wall  into  the  mucous  membrane  ;  the  vessels  of  this  mem- 
brane, having  undergone  fatty  degeneration,  give  way,  and  extravasation 
of  blood  results.  This  extravasation  takes  place  always  near  the  surface, 
for  in  that  situation  the  degenerative  change  has  most  advanced.  The 
rush  of  blood  into  the  vessels  of  the  mucous  membrane  expels  the  con- 
tents of  the  glands,  together  with  the  greater  part  of  their  lining  epithe- 
lium. .  .  .  When  hemorrhage  has  taken  place  into  the  membrane,  it 
undergoes  rapid  disintegration,  and  becomes  entirely  removed.  .  .  ." 

The  new  mucous  membrane  "is  produced  by  proliferation  of  the 
elements  of  the  muscular  wall  of  the  organ,  the  muscular  fibres  produ- 


ANATOMY    OF    THE    FEMALE    PELVIC    ORGANS. 


cing  the  fusiform  cells,  the  connective  tissue,  the  round  cells,  and  the 
groups  of  round  cells  in  the  meshes  formed  by  the  muscular  bundles,  the 
glandular  epithelium." 

Entire  removal  of  the  mucous  membrane  and  its  regeneration  from  the 
muscular  coat,  are  the  essentials  of  Williams'  views. 

(2.)  Kundrat  and  Engelmann  describe  the  change  at  the  menstrual  pe- 
riod as  follows  : 

Mucous  membrane  becomes  swollen  and  pulpy,  and  measures  in  thick- 
ness 3 — 6  mm.  The  thickness  is  most  marked  at  the  fundus  and  central 


Eg,  68. 

Diagram  of  uterus  just  before  menstruation. 
The  shaded  portion  represents  the  mucous  mem- 
brane (J.  Williams). 


Fig.  69- 

Diagram  of  uterus  when  menstruation  has  ju^t 
ceased,  showing  the  cavity  of  the  body  deprived 
of  mucous  membrane  ( J.  Williams). 


portions  of  the  anterior  and  posterior  surfaces.     The  surface  is  puffy  and 
injected  ;  glands  are  distinctly  seen  on  section  as  fine  spirals. 

Microscopically,  this  increase  in  thickness  is  seen  to  be  due  to  a  pro- 
liferation of  the  round  cells  of  the  stroma,  an  enlargement  of  all  the  cell 
elements  in  the  superficial  layers,  and  an  increase  of  the  intercellular  sub- 
stance. This  superficial  layer  has  grown  far  above  the  original  gland 
openings,  causing  the  funnel-shaped  depressions  or  small  pits  seen  on  sur- 
face view.  The  glands  are  increased  in  thickness  and  length.  The  vessels 
are  enlarged  and  gorged  with  blood.  Fig.  70  shows  the  mucous  mem- 
brane of  the  menstruating  uterus  magnified  40  times  ;  it  should  be  com- 


90 


MANUAL    OF    GYNECOLOGY. 


pared  with  the  mucous  membrane  of  the  non-menstruating  uterus  at  Fig. 
19,  also  magnified  40  times. 

The  increase  of  the  thickness  of  the  mucous  membrane  begins  as  the 
time  of  menstruation  approaches,  is  most  marked  during  the  period  itself, 
and  gradually  decreases  after  the  cessation  of  the  catamenial  flow. 

Fatty  degeneration  takes  place  in  the  cells  of  the  interglandular  tissue, 
blood-vessels,  and  glandular  and  surface  epithelium. 

They  hold  that  "  the  hemorrhage  is  always  confined  to  the  surface  of 


Fig;  7fc 

Mucous  membrane  of  menstruating  uterus  (4%,  Knndrat  and  Engelmann). 

the  lining  membrane,  and  is  due  to  the  fetidly  degenerated  tissue  being 
unable  to  resist  the  blood  pressure  ;  "  and  they  therefore  maintain,  what  is 
most  probably  the  case,  that  only  the  superficial  layer  of  the  mucous  membrane 
is  shed  at  a  menstrual  period. 

(3.)  Leopold  denies  the  existence  of  any  fatty  degeneration  of  the 


ANATOMY    OF   THE   FEMALE    PELVIC    ORGANS.  91 

superficial  layers  of  the  mucous  membrane.  He  believes  that  an  extra- 
vasation of  red  and  white  blood-corpuscles  from  the  superficial  capillaries 
takes  place  especially  towards  the  superficial  layer,  undermining  the 
uppermost  layer  of  cells  ;  and  that,  finally,  the  copious  supply  of  blood 
reaching  these  capillaries  from  the  numerous  arteries  causes  rupture  and 
bleeding.  The  mucous  membrane  is  regenerated  by  an  upward  growth 
of  the  glandular  epithelium. 

Williams,  Kundrat,  Engelmann,  and  Leopold  examined  uteri  from  post- 
mortem cases.  Recently  Miiricke  has  curetted  the  uteri  of  living  women  at 
various  stages  of  their  menstruation,  and  microscopically  examined  what 
he  removed.  He  asserts  that  "during  menstruation  the  mucous  membrane 
disappears  neither  partially  nor  fully."  This  shows  how  widely  micro- 
scopists  vary.  Williams  says  all  the  mucous  membrane  is  removed  ;  Kun- 
drat, Engelmann,  and  Leopold  say  only  the  superficial  layers  are  removed  ; 
and  Miiricke  says  none  is  removed. 

We  have  deemed  it  best  to  lay  these  views  before  the  student.  The 
subject  is  difficult  to  investigate,  and  one  on  which  the  authors  are  not 
qualified  to  give  an  opinion.  They  incline,  however,  to  the  views  of  Kun- 
drat, Engelmann,  and  Leopold.  The  chief  difficulty  in  regard  to  Williams' 
view  is  the  regeneration  of  the  new  mucous  membrane  from  the  muscular 
coat. 

Finally,  it  should  be  noted  that  almost  all  observers  consider  ovulation 
and  menstruation  as  occurring  together.  Beigel's  view,  that  ovulation  oc- 
curs at  any  time  and  that  menstruation  is  a  mere  evidence  of  sexual  excite- 
ment, has  found  no  supporters. 

A  dispute  still  exists  as  to  which  ovum  is  fertilized  when  pregnancy 
occurs — the  ovum  of  the  bleeding  period,  or  that  of  the  first  period 
missed.  Many  observers  believe  in  Loewenhardt's  theory,  viz.,  that  the 
ovum  fertilized  is  that  of  the  first  period  missed. 

Lately  the  dominant  influence  of  the  ovary  in  menstruation  has  been 
questioned  by  some,  notably  by  Lawson  Tait.  The  operation  known  as 
Battey's  operation,  where  both  ovaries  are  removed,  does  not  always 
cause  a  cessation  of  menstruation.  Tait  asserts  that  menstruation  will 
always  cease  if  the  Fallopian  tubes  are  also  excised ;  and  therefore 
believes  that  they  play  an  important  part  in  menstruation,  hitherto  un- 
suspected. 

Leopold's  monograph  is  illustrated  by  many  valuable  lithographs,  and 
the  same  may  be  said  in  regard  to  Dalton's  work  on  the  Corpus  Luteum. 


SECTION  II. 

PHYSICAL  EXAMINATION   OF  THE  FEMALE 
PELVIC   ORGANS. 

IK  tliis  section  we  have  to  take  up  the  physical  examination  of  the 
female  pelvic  organs,  that  is  exploration  by  the  hands  and  instruments  of 
the  gynecologist.  This  will  be  considered  in  the  following  manner  : 

CHAPTER  VIL     Abdominal  Examination  :    Vaginal  Examination  :    the 
Bimanual  Examination,  with  its  various  modifications. 


CHAPTER  Vm.     Examination  per  Eectum. 

CHAPTER  IX.     The  Volsella. 

CHAPTER  X.     Vaginal  Specula. 

CHAPTER  XI.     The  Uterine  Sound. 

CHAPTER  XII.     Sponge  Tents  and  other  Uterine  Dilators. 

CHAPTER  XIH.     The  Curette. 

CHAPTER    XIV.      Knives,    Scissors,    Needles,    Sutures,    Antiseptics, 
Douches  and  Syringes,  Anesthetics. 


CHAPTER  VII. 

ABDOMINAL    EXAMINATION :    VAGINAL    EXAMINATION :    THE    BI- 
MANUAL  EXAMINATION  WITH  ITS  VAEIOUS  MODIFICATIONS. 

IN  a  female  patient  whose  symptoms  point  to  a  pelvic  cause,  it  is  neces- 
sary to  investigate  the  case  by  what  is  commonly  known  as  a  vaginal 
examination.  A  mere  vaginal  examination,  however,  gives  very  little 
information.  The  proper  method  is  first  to  make  an  external  abdominal 
examination  and  then  the  vaginal  examination,  the  latter  being  only  a 
stage  of  the  more  complete  method  of  investigation  known  as  the  bi-man- 
ual.  Special  cautions  as  to  cases  unsuitable  for  pelvic  exploration  are 
given  under  the  head  of  vaginal  examination.  We  consider  the  examina- 
tion in  the  following  order  : — 

I.  External  abdominal  examination. 
n.  Inspection  of  external  genitals  (only  when  necessary). 

m.  Vaginal  examination. 

IV.  The  bi-manual  or  abdomino-vaginal  examination. 

EXTERNAL    ABDOMINAL    EXAMINATION. 

The  patient  should  lie  on  her  back  with  her  knees  drawn  up  and  her 
head  supported  on  a  pillow.  The  bowels  and  bladder  should  be  empty. 
The  abdominal  surface  should  be  bared  and  exposed  from  the  epigastrium 
downwards  ;  no  part  of  the  mons  veneris  should  be  uncovered.  The  most 
delicate  method  of  accomplishing  this  is  as  follows  :  A  sheet  or  blanket 
should  be  thrown  over  the  recumbent  patient ;  beneath  this  she  should 
raise  up  her  dress  as  far  as  the  pit  of  the  stomach ;  the  examiner  then 
places  his  one  hand  on  the  sheet,  a  little  above  the  mons  veneris,  and 
turns  it  down  over  it  with  his  other  hand.  The  abdominal  surface  is 
examined  in  four  ways,  viz.,  inspection,  palpation,  percussion,  ausculta- 
tion. 

A.  Inspection. — The  form,  color,  equality  or  inequality  of  bulge  of  the 


96  MANUAL    OF    GYNECOLOGY. 

abdominal  surface  should  be  noted ;  the  presence  or  absence  of  the  linea 
nigra,  lineae  albicantes  (fresh  and  old),  pigmentary  deposits,  fat  streaks, 
and  skin  eruptions.  The  linea  nigra  has  no  significance.  The  lineee  albi- 
cantes indicate  that  the  patient's  abdominal  cavity  is  or  has  been  dis- 
tended beyond  the  normal.  They  are  not  specially  significant  of  preg- 
nancy. Fresh  linese  albicantes  are  glistening  and  pearly  ;  old  ones  have  a 
dull  white  or  scarred  appearance. 

B.  Palpation  should  be  performed  with  both  hands.  For  this  purpose 
the  hands,  well  warmed,  are  laid  flat  on  the  abdominal  surface  and  the 
whole  area  manipulated  between  them.  One  hand  alone  is  of  no  use.  By 
this  method  the  abdominal  contents  are  compressed  and  driven  between 
the  hands.  The  feeling  given  normally  is  that  of  manipulating  a  plastic 
fluid.  Tapping  with  one  index  finger  so  as  to  give  a  fluctuating  impulse 
to  the  other  hand  is  of  great  value.  Circumscribed  nodules  or  tumors, 
fluid  collections,  thickening  of  the  skin,  should  be  noted  and  mapped  out 
on  the  scheme  given  in  the  chapter  on  case-taking. 

For  the  more  exact  localization  of  the  normal  and  abnormal  abdominal 
contents,  anatomists  divide  the  anterior  abdominal  surface  into  definite 
regions  by  vertical  and  transverse  lines.  The  lower  transverse  line  is 
drawn  at  the  level  of  the  anterior  superior  iliac  spines  ;  the  upper  one, 
between  the  most  prominent  parts  of  the  ninth  costal  cartilages.  A  ver- 
tical line  joining  the  cartilage  of  the  eighth  rib  with  the  middle  of  Pou- 
part's  ligament  on  each  side,  completes  the  division  into  nine  areas,  which 
are  named  in  order  as  follows  (vide  Plate  I.). 

Eight  Hypochondriac  (5).      Epigastric  (4).       Left  Hypochondriac. 
"     Lumbar  (7).  Umbilical  (6).  "    Lumbar. 

"     Iliac  (9).  Hypogastric  (8).      "    Iliac. 

In  these  regions  the  following  structures  are  found  : — 
Epigastric  region. — Right  part  of  stomach  ;  pancreas  ;  liver. 
Right  Hypochondriac. — Right  lobe  of  liver  ;   gall-bladder,  part  of  duode- 
num ;  hepatic  flexure  of  colon  ;  part  of  right  kid- 
ney, and  its  suprarenal  capsule. 

Left  Hypochondriac. — Cardiac  end  of  stomach ;  spleen  and  narrow  ex- 
tremity of  the  pancreas  ;  the  splenic  flexure  of  the 
colon  ;  the  upper  part  of  the  left  kidney,  with  the 
left  suprarenal  capsule  ;  sometimes  also  a  part  of 
the  left  lobe  of  the  liver. 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS.      97 

Umbilical — Part  of  the  omentum  and  mesentery  ;  the  transverse  part  of 
the  colon  ;  lower  part  of  the  duodenum,  with  some 
convolutions  of  the  jejunum  and  ileum. 
Right  Lumbar. — The  ascending  colon  ;  lower  half  of  the  kidney  ;  and  part 

of  the  duodenum  and  jejunum. 
Left  Lumbar. — The  descending  colon  ;  lower  part  of  the  left  kidney,  with 

•  part  of  the  jejunum. 

Hypogastric. — The  convolutions  of  the  ileum  ;  the  bladder  in  children,  and, 
if  distended,  in  adjilts  also  ;  the  uterus  when  in 
the  gravid  state. 

Eight  Iliac. — The  caecum,  with  the  appendix  vermiformis,  and  the  termina- 
tion of  the  ileum. 
Left  Iliac. — The  sigmoid  flexure  of  the  colon.     (Quain.) 

Plate  HE.  shows  a  valuable  coronal  section,  published  by  Euedinger ; 
it  should  be  carefully  studied.  The  numbers  refer  to  the  following 
structures : 

1.  Bight  lung.  2.  Eight  auricle ;  to  its  left  is  the  larger  coronary 
vein.  4.  Eight  branch  of  pulmonary  artery.  The  shorter  left  branch  is 
seen  at  the  left.  7.  Liver.  Note  the  impression  on  its  under  and  right 
side  from  the  right  flexure  of  the  colon.  8.  Stomach.  Note  how  its  long 
axis  is  vertical  and  that  the  main  bulk  of  the  stomach  is  to  the  left  of  the 
middle  line.  9.  Ascending  colon.  9*.  Opening  of  small  intestine.  10. 
Small  piece  of  junction  between  stomach  and  duodenum.  11.  Pancreas. 
12.  Duodenum.  13-13.  Small  intestine.  14.  Fundus  uteri.  15.  Bladder, 
with  ureteric  openings.  16.  Connective  tissue.  17.  Descending  colon. 
18.  Sigmoid  flexure.  19.  Mesentery. 

In  palpating  the  normal  abdomen,  the  sensation  given  is  one  of  im- 
pulse communicated  generally  through  a  plastic  fluid.  When  free  fluid  is 
in  the  abdominal  cavity  the  impulse  is  more  distinct.  When  the  fluid  is 
encysted,  the  impulse  and  tense  feeling  are  localized. 

When  any  large  body  is  felt  in  the  abdominal  cavity,  the  first  point  to 
be  determined  is  whether  the  body  is  pelvic  or  abdominal.  This  is  easily 
done  by  attempting  to  press  the  hand  downwards  just  above  the  sym- 
physis  pubis.  If  the  tumor  is  pelvic  and  rising  up  into  the  abdomen,  the 
hand  cannot  be  so  pressed  ;  and  conversely. 

In  all  tumors,  the  existence  or  non-existence  of  intermittent  contrac- 
tions should  be  carefully  noted.  Their  presence  indicates  a  uterine 

tumor — pregnancy  or  soft  fibroid. 
VOL.  I.— 7 


98  MANUAL    OF    GYNECOLOGY. 

The  following  general  points  should  be  kept  in  mind.  The  bladder  is 
only  in  the  hypogastric  region  when  distended  or  displaced  upwards :  if 
empty  it  is  behind  the  pubis,  and  in  the  true  pelvis  :  a  distended  bladder 
may  be  as  large  as  a  six  months'  pregnancy.  Ovarian  tumors  are  more  or 
less  lateral ;  uterine  tumors  generally  central,  although  the  pregnant 
uterus  has  usually  a  right  lateral  obliquity.  In  advanced  pregnancy,  the 
parts  of  the  foetus  can  be  distinctly  palpated.  Finally,  it  should  be  -kept 
in  mind  that  in  all  cases  of  cystic  tumors  the  catheter  should  be  passed 
into  the  bladder,  for  an  obvious  reason. 

CASE. — Mrs.  A.  was  sent  for  consultation  as  to  removal  of  internal 
tumor.  On  examination,  a  cystic  tumor  was  felt  mesially  in  the  abdomen 
and  reaching  up  to  umbilicus.  Vaginal  and  bi-manual  examinations  were 
exceeding  painful.  A  catheter  passed  into  the  bladder  evacuated  a  large 
amount  of  urine.  The  uterus  was  now  found  to  be  retroverted  and  gravid 
3£  months,  and  the  cystic  tumor  had  disappeared. 

C.  Percussion  is  to  be  performed  in  the  usual  way.     To  perform  this 
thoroughly,  the  patient  should  be  percussed  (a)  when  on  her  back  ;  (6) 
when  on  her  left  side  ;  (c)  when  on  her  right  side  ;  (d)  when  sitting  up. 
Changes  in  the  percussion  note  on  the   patient  changing  her  posture 
should  be  carefully  noted  as  they  are  of  great  value  (vide  under  Ovarian 
Tumours  and  Ascites). 

D.  Auscultation  is  of  great  value,  and  is  performed  with  the  ordinary 
stethoscope.    The  fcetal  heart,  uterine  souffle  and  friction  may  be  heard  by 
it.    The  importance  of  auscultation  is  evident.    Fcetal  heart-sounds  indicate 
pregnancy  ;  the  point  of  greatest  intensity  of  the  heart-sounds  indicate  the 
lie  of  the  child.     Uterine  souffle  and  no  heart-sounds  indicate  either  preg- 
nancy and  child  dead,  or  fibroid  tumor.     Ovarian  cysts  have  no  souffle. 

Before  finishing  abdominal  examination,  the  patient  should  be  made  to 
raise  her  shoulders  by  grasping  the  examiner's  hand.  When  there  is  no 
encysted  abdominal  tumour  the  recti  can  be  seen  to  flatten  the  abdominal 
contour  ;  if,  however,  a  solid  or  cystic  tumour  be  present  the  contour  is 
unaltered.  An  exception  should  be  made  in  the  case  of  thin-walled  cysts 
with  fluid  of  a  low  specific  gravity,  where  the  recti  do  flatten  the  contour 
as  in  the  former  case. 

r 

INSPECTION   OF   EXTERNAL   GENITALS. 

This  should  not  be  made  a  routine  practice.  As  a  general  rule,  in- 
spection of  the  genitals  should  only  be  made  when  there  is  local  tender- 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS.      99 

ness,  where  syphilis  or  gonorrhoea  is  suspected,  or  where  it  is  said  by  the 
patient  that  something  comes  down  at  the  vaginal  orifice.  Soft  chancres, 
hard  chancres  (almost  never  seen  in  females),  mucous  patches,  condylo- 
mata  ;  urethral  caruncles ;  irritable  spots  causing  vaginismus ;  labial  ab- 
scess ;  parturition  tears  of  perineum  and  labia  ;  prolapsed  pelvic  organs  ; 
external  or  internal  piles,  may  be  found. 

VAGINAL   EXAMINATION. 

Preliminaries. — "Vaginal  examination  should  not  be  made  on  girls  below 
or  little  beyond  the  age  of  puberty,  unless  the  symptoms  are  urgent,  e.g., 
mechanical  retention  of  menstrual  fluid  from  atresia.  In  the  case  of  un- 
married women  it  should  not  be  performed  unless  specially  necessary.  In 
both  classes  of  patients  the  value  of  a  rectal  examination  should  be  kept  in 
mind.  The  vaginal  examination  should  be  made  on  married  women  whose 
symptoms  point  to  a  pelvic  cause.  Finally,  no  woman  should  be  examined 
vaginally  when  menstruating  normally,  unless  under  exceptional  circum- 
stances. 

After  settling  these  preliminaries  and  having  obtained  the  patient's 
consent  to  "  examine "  (a  term  understood  by  all  women  as  meaning  a 
vaginal  examination),  the  next  point  is  to  determine  the  position  the 
woman  is  to  occupy  while  the  examination  is  going  on. 

In  this  country  it  is  customary  to  place  the  woman  on  her  left  side  for 
the  vaginal  examination,  and  to  turn  her  on  her  back  for  the  performance 
of  the  bimanual.  The  patient,  therefore,  lies  on  a  convenient  couch  with 
her  knees  well  drawn  up  and  her  clothes  loose.  The  examiner  carefully 
oils  or  soaps  the  index  and  middle  finger  of  his  right  hand.  With  his  left 
hand  he  clears  away  the  clothes  from  the  hips  so  as  to  make  a  passage  for 
the  examining  fingers,  which  he  passes  onwards  till  he  reaches  the  cleft 
between  the  buttocks.  He  next  passes  them  forwards  over  the  anus,  skin 
over  base  of  perineum  and  fourchette,  until  the  pulp  of  the  finger  rests  at 
the  vaginal  orifice.  In  multiparous  women,  the  lax  vaginal  orifice  is  easily 
felt.  When  in  doubt,  the  student  should  pass  his  fingers  cautiously  on 
until  he  touches  the  vestibule,  which  is  always  smooth.  Passing  his  fingers 
back  he  will  then  reach  the  vaginal  orifice  at  the  base  of  the  vestibule.  t 

The  student  must  be  careful  not  to  pass  his  finger  into  the  rectum  by 
mistake.  He  should  remember  that  the  vaginal  axis  passes  backwards, 
the  anal  axis  forwards  ;  that  no  force  is  required  to  pass  his  finger  into 


100  MANUAL    OF    GYKECOLOGY. 

the  vagina  of  a  woman  whose  hymen  has  been  ruptured,  whereas  some 
force  is  necessary  to  overcome  the  resistance  of  the  sphincter  ani  in  all 
women.  The  clitoris,  lying  at  the  apex  of  the  vestibule,  should  never  be 
touched  digitally. 

The  two  fingers  being  now  at  the  vaginal  orifice  should  be  carried 
backwards  into  the  vagina  until  its  upper  limits  are  felt.  While  doing  so 
the  student  should  note — 

1.  State  of  vaginal  orifice  ;  patulous  or  narrow,  presence  or  absence  of 
painful  spots,  presence  or  absence  of  spasm. 

2.  Walls  ;  presence  or  absence  of  rugse  ;  moisture,  heat,  secretion,  tu- 
mours attached  to  them  ;  fistulse  ;  foreign  bodies  such  as  pessaries,  gly- 
cerine plug,  oakum  plug  ;  shape  of  walls,  length  of  walls. 

3.  Cervix ;  direction,  size,  shape,  and  consistence.     Note  especially  if 
thickened,  expanded,  and  fixed  ;  drawn  to  one  or  other  side  ;  or  if  mobile 
and  not  fixed  ;  or  if  split  and  with  cicatrices  radiating  from  it  to  vaginal 
roof. 

4.  Os  ;  size,  shape,  consistence  of  lips.     Thus  it  may  be  a  dimple  as 
in  nulliparse  ;  transverse  as  in  parous  women  (Figs.  13  and  14)  ;  or  the 
cervix  may  be  split  on  one  or  both  sides  and  thus  no  os  externum  is  pres- 
ent, but  the  cervical  canal  is  more  or  less  exposed  (Plate  VIII.).     Bodies, 
projecting  through  it  should  be  noted.    They  may  be  polypi,  fragments  of 
abortion,  cancerous  masses,  stem  pessaries. 

5.  Posterior  fornix  is  concave  when  felt  from  below.     It  has  normally 
a  feeling  like  that  of  the  inside  of  the  angle  of  the  mouth.     Note  if  any 
lump  can  be  felt  through  it,  projecting  down  from  Douglas  pouch,  render- 
ing the  fornix  convex.     A  body  or  a  feeling  of  resistance  in  the  posterior 
fornix  may  be — 

(1.)  Faeces; 

(2.)  Acute  or  chronic  inflammatory  deposit,  cicatrization  of  utero- 

sacral  ligaments  ; 
(3.)  Eetroverted  fundus  uteri  ; 
(4.)  Blood  effusion ; 

(5.)  Fibroid  attached  to  posterior  wall  of  uterus ; 
(6.)  Ovary  inflamed  or  cystic ; 
(7.)  Ascitic  fluid  ; 
(8.)  Extra-uterine  fcetation  or  hydatid  (rare). 

6.  Anterior  fornix. — Note  if  there  is  any  body  felt  through  it.     If  so, 
it  is  most  probably  the  fundus  uteri,  normal  or  enlarged  from  pregnancy 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS. 


101 


or  fibroid.  There  may  be  also  inflammatory  or  blood  effusion,  or  a  tender 
ovary,  but  these  are  rare  here. 

7.  Lateral  Fornices. — Note  cicatrices,  prolapsed  or  cystic  ovary,  lateri- 
flexed  uterus,  inflammatory  or  blood  effusion  in  broad  ligament,  dilatation 
of  Fallopian  tubes,  fibroids  placed  laterally. 

The  vaginal  examination  has  now  been  completed.  The  student 
should  keep  in  mind  that  he  really  learns  very  little  from  a  vaginal  exam- 
ination, just  as  he  can  learn  very  little  as  to  the  size  and  relation  of  any 
object  by  touching  it  with  the  fingers  on  a  but  limited  area.  Vaginal 
examination  is  thus  only  the  preliminary  to  the  bimanual  or  abdomino- 
vaginaL 

BIMANUAL   OB   ABDOMINO-VAGINAI,    EXAMINATION. 

This  method  of  examination  is  the  all-important  one  in  gynecology 
and  is  the  one  which  the  student  and  practitioner  will  find  most  valuable, 
so  that  its  practice  should  precede  all  other  methods  of  internal  investi- 


Fig.  71. 
Bight  hand  as  in  bimanual  examination. 

gation.  As  the  practitioner's  experience  increases,  he  will  find  that  he 
relies  more  upon  this  and  becomes  less  dependent  on  other  means  of 
examination. 

Method  of  performing  Bimanual.  Position  of  Patient. — The  patient 
must  now  be  made  to  lie  on  her  back.  The  head  and  shoulders  should 
be  supported  and  the  knees  drawn  up. 

Arrangement  of  Examiner's  Hands. — The  internal  hand  (the  right)  is 
placed  as  follows:  two  fingers  (index  and  middle)  are  in  the  vagina,  the 
thumb  rests  in  the  fold  between  a  labium  majus  and  the  thigh,  and  the 
other  fingers  lie  in  the  cleft  of  the  nates,  Fig.  71.  The  whole  hand  is 


102 


MANUAL    OF    GYNECOLOGY. 


then  rotated  backwards  so  as  to  bring  its  long  axis  as  nearly  as  possible 
into  the  axis  of  the  brim,  and  is  then  pushed  up  towards  the  biim  of  the 
pelvis.  Thus  the  pubic  segment,  uterus  with  annexa,  and  posterior  vagi- 
nal wall  are  lifted  up  towards  the  brim.  The  middle  finger  is  placed 
over  the  os  and  the  index  one  in  the  anterior  fornix,  so  that  the  uterus 
as  it  is  pushed  up  becomes  more  anteverted.  The  right  hand  while  ex- 
amining, therefore,  has  the  appearance  at  Fig.  71.  The  little  and  ring 
fingers  may  be  doubled  up  as  in  Fig.  72.  The  external  hand  (the  left)  is 
placed  on  the  abdominal  wall  just  above  the  pubis,  with  its  long  axis 


Fig.  72. 

Bimanual  examination.    The  upper  hand  is  not  shown  (Hart). 

running  obliquely  between  the  iliac  crests,  its  ulnar  edge  near  the  pro- 
montory and  much  deeper  than  the  radial  one.  It  is  now  steadily  de- 
pressed until  the  abdominal  wall  below  it  is  markedly  cupped  (Figs.  72 
and  73)  and  moulded  over  the  uterus,  ovaries,  etc.,  which  have  been 
elevated  by  the  inner  hand.  In  this  way  the  two  hands  estimate  the  size 
and  relations  of  the  pelvic  contents,  just  as  one  would  estimate  the  size 
of  a  watch  covered  with  a  cloth.  The  student  should  note  specially  that 
the  upper  hand  should  be  steadily  and  not  spasmodically  depressed ;  that 
he  should  always  keep  the  ulnar  edge  of  this  hand  deeper,  that  is,  nearer 
the  sacrum,  so  that  he  may  not  retrovert  the  uterus  ;  and  that  he  should 
palpate  all  the  abdominal  areae  along  the  pelvic  brim  so  as  not  to  miss 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS. 


103 


anything.  His  first  object  in  the  bimanual  examination  is  to  determine 
where  the  uterus  is,  as  this  greatly  simplifies  the  recognition  of  abnormal 
products  in  the  pelvis.  He  then  bimanually  explores  the  fornices,  moving 
the  internal  fingers  appropriately  and  noting  what  he  feels.  At  first  his 
diagnosis,  should  be  simply  bimanual,  e.g.,  "uterus  felt  to  front  and  a 


Fig.  73. 
Anterior  abdominal  surface  of  female,  with  upper  hand  placed  for  bimanual  (ad  naturam). 

large  firm  lump  behind  it ; "  or,  "  uterus  felt  retroverted  and  a  small  mov- 
able tumor  on  its  left  side. " 

It  is  of  importance  that  the  student  should  know  what  a  "normal  bi- 
manual "  is.  The  following  is  a  description  of  the  condition  found  in  a 
nulliparous  married  woman,  on  vaginal  and  bimanual  examination  : 

"  Ostium  vaginse  patulous,  and  admits  two  fingers ;  vaginal  walls 
moist,  rugous,  with  no  abnormalities.  Vaginal  portion  of  cervix  normal 
in  size  (Fig.  13)  ;  os  uteri  felt  like  a  dimple,  looking  downwards  and 
backwards.  No  bodies  are  felt  through  the  lateral  and  posterior  fornices, 
which  are  concave  on  their  vaginal  aspects  and  have  the  feeling,  on  press- 
ure, of  the  angle  of  one's  mouth.  In  the  anterior  fomix  a  body  is  felt, 


104 


MANUAL    OF    GYNECOLOGY. 


which  on  bimanual  examination  is  discovered  to  be  the  uterus  lying  to 
the  front  and  not  enlarged.  The  fundus  and  cervix  meet  at  a  very  large 
angle.  Bimanual  exploration  of  the  fornices  reveals  nothing  distinctly 
•palpable.1  The  patient  complains  of  no  pain  during  the  whole  examina- 
tion, and  has  no  symptoms  referable  to  the  pelvis." 

Cases  where  the  Bimanual  is  difficult.— The  student  will  soon  find  that 
the  bimanual  can  be  performed  in  certain  cases  with  great  facility  and 
accuracy,  while  in  other  women  it  is  exceedingly  unsatisfactory. 

The  best  case  for  a  bimanual  is  a  woman  a  fortnight  or  three  weeks 
after  delivery.  The  reasons  for  this  are  evident.  A  puerperal  woman  has 


Pig.  U. 

Displacement  of  pelvic  floor  segments  and  abdominal  wall  in  bimanual  (Hart). 

had  the  ostium  vaginae  and  vaginal  walls  relaxed  by  the  child's  head ;  the 
pubic  segment  has  been  drawn  up  and  its  attachments  slackened ;  the 
abdominal  walls  have  had  their  elasticity  diminished  by  the  full  time 
uterus,  and  the  uterus  itself  is  not  involuted  to  its  normal  size.  In  such  a 
case  there  are  evidently  all  the  requisites  for  a  good  bimanual. 

Difficult  bimanual  cases  are  found  in  stout  nulliparous  women,  and  in 
cases  of  pelvic  inflammation.  In  such,  the  rectal  examination,  with  or 
without  the  use  of  the  volsella,  is  indicated. 

1  One  practised  in  the  bimanual  can  feel  the  normal  ovaries. 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS.  105 

Students  at  first  find  their  bimanual  unsatisfactory.  By  perseverance, 
however,  they  will  obtain  by  means  of  it  an  accuracy  in  diagnosis  which 
is  astonishing.  It  is  not  only  the  best  means  of  investigation,  but  one 
from  which  no  possible  harm  can  arise.  In  no  cases  is  it  contra-indicated 
except  those  of  advanced  cancer  or  of  acute  inflammation. 

We  have  described  the  simple  abdomino-vaginal  examination.  It  will 
be  readily  understood  that  we  may  have  others,  as  follows  : 

(1.)  Recto-abdominal  (finger  in  rectum  and  left  hand  above)  ; 

(2.)  Recto-vagino  abdominal  (middle  finger  in  rectum,  index  finger 

in  vagina,  and  left  hand  above)  ; 
(3.)  Vesico-vagino-abdominal   (middle   finger  in   vagina,   index  in 

bladder,  and  hand  above). 
Of  these  the  third  is  very  rarely  practised. 

Note  that  in  the  Bimanual  the  pubic  segment  ivith  uterus  and  its  annexa 
are  elevated,  the  sacral  segment  shortened,  and  the  abdominal  walls  depressed 
(Fig.  74). 

After  the  bimanual  or  other  examination  is  finished,  the  examiner 
should  scrupulously  cleanse  his  hands.  There  are  no  better  nor  cheaper 
substances  for  this  than  turpentine  and  ordinary  soap,  as  Dr.  Foulis  of 
Edinburgh  has  shown.  The  odor  is  by  no  means  disagreeable,  and  if 
found  objectionable  can  be  easily  covered  by  vinegar  which  in  itself  is  a 
good  cleanser.  In  examining  cancerous  cases,  where  the  odor  is  exceed- 
ingly penetrating  and  persistent,  it  is  a  good  plan  to  dip  the  fingers  in 
turpentine  prior  to  the  examination. 


CHAPTER  Yin. 
EXAMINATION  PEE  EECTUM. 

LITERATURE. 

Hegar — Die  operative  Gynakologie,  zweite  Auflage  :  Stuttgart,  1881  :  Munde — Minor 
Gynecology :  Wood  &  Co.,  New  York,  1881.  Consult  Hegar  for  additional  refer- 
ences. 

THE  results  obtained  by  a  vaginal  examination  are  limited  by  the  fact  that 
the  reflection  of  the  vaginal  walls  to  form  the  fornices,  prevents  the  finger 
being  pushed  up  to  a  sufficient  distance.  This  defect  is  compensated  for 
by  the  downward  pressure  of  the  upper  hand  in  the  Bimanual ;  but  in 
those  other  cases  where  the  abdominal  walls  are  unyielding  and  the  pubic 
segment  stiff,  due  pelvic  exploration  by  an  ab domino-vaginal  examination 
alone  is  impossible.  In  such  cases,  rectal  exploration  and  the  abdomino- 
rectal  or  abdomino-recto- vaginal  examination  are  invaluable.  They  give 
better  information  than  the  more  commonly  practised  abdomino-vaginal 

The  usual  methods  are — 

(1.)  Simple  rectal ;  abdomino-rectal ;  abdomino-recto-vaginal. 

(2.)  Passage  of  the  whole  hand  into  the  rectum  (Simon's  method). 

SIMPLE   RECTAL  ;    ABDOMINO-RECTAL  J   ABDOMINO-RECTO-VAGINAL. 

Preliminaries. — The  patient  should  be  told  that  it  is  necessary  to  ex- 
amine the  bowel.  If  the  rectum  is  loaded  the  examination  should  be 
deferred  till  next  day,  and  the  patient  instructed  to  use  a  purgative  at 
night  and  an  enema  in  the  morning. 

The  following  points  should  be  especially  noted  : — The  examiner  should 
thoroughly  soap  the  fingers  and  nails.  A  vaginal  examination  may  be 
made  first ;  and  then,  the  index  finger  being  kept  in  the  vagina,  the 
middle  one  is  passed  into  the  rectum  (Fig.  75).  If  the  patient  is  virginal 
and  it  is  wished  to  avoid  a  vaginal  examination,  then  the  index  finger 
alone  is  passed  into  the  rectum.  When  the  finger  or  fingers  are  with- 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS.  107 

drawn  from  the  rectum  the  hands  should  be  at  once  cleansed  ;  there  can 
be  nothing  more  hurtful  to  a  patient's  feelings  than  the  passing  of  the 
uncleansed  fingers  from  the  rectum  into  the  vagina.  The  patient  lies  first 
on  her  left  side  and  then  on  her  back. 

'  The  finger  passed  into  the  rectum  goes  forward  ;  when  passed  into  the 
vagina,  the  direction  is  backwards.  After  overcoming  the  resistance  of 
the  strong  external  sphincter  it  enters  the  rectal  ampulla  (Fig.  36),  which 
is  often  expanded  by  flatus.  Passing  the  finger  onwards  and  to  the  left 


Kg.  75, 

Abdomlno-recto-vaginal  examination.    Upper  hand  not  shown.    Note  prolapsed  ovary. 

side,  a  confused  mass  of  tissue  is  felt  in  which  we  may  detect  the  opening 
betwixt  the  segments  of  the  sphincter  tertius. 

As  we  pass  the  finger  inwards  we  note  piles  (internal  and  external), 
fissures,  polypi,  ulcers,  stricture  (specific  and  malignant). 

We  next  turn  the  pulp  of  the  examining  finger  so  that  it  lies  on  the 
anterior  rectal  wall.  Through  this  can  be  felt  the  cervix.  Note  that  the 
whole  cervix  is  felt,  which  is  much  larger  than  the  vaginal  portion  felt  on 
vaginal  examination.  Be  sure  not  to  mistake  it  for  the  body  of  the 
uterus.  If  the  uterus  lies  to  the  front  its  forward  direction  can  be  noted  ; 


108  MANUAL    OF    GYNECOLOGY. 

if  to  the  back,  then  the  body  will  be  felt  on  passing  the  finger  further  up. 
Pushing  the  finger  well  upwards  and  passing  it  first  to  the  right  and  then 
to  the  left,  we  feel  the  ovaries  (more  distinctly  when  enlarged)  as  small 
oval  tender  bodies  (Fig.  75). 

Fig.  40  shows  a  common  condition  of  the  uterus  which  is  constantly 
mistaken  for  and  treated  as  a  retroversion.  We  allude  to  the  uterus 
anteflexed  and  drawn  back  by  pelvic  cellulitis  of  the  utero-sacral  liga- 
ments. As  the  patients  are  usually  sterile  and  have  therefore  somewhat 
unyielding  abdominal  walls  which  cause  a  difficult  bimanual,  and  as  a 
lump  is  felt  in  the  posterior  fornix,  the  diagnosis  of  retroversion  is  often 
made.  The  rectal  examination,  however,  clears  up  the  case,  as  the  finger 
feels  the  knee  of  the  flexion  and  the  fundus  going  forward  from  it. 

The  upper  hand  is  used  during  the  rectal  examination  just  as  in  the 
bimanual,  i.e.,  the  examination  is  abdomino-recto-vaginal  or  abdomino- 
rectal.  The  simple  rectal  (with  the  finger  in  the  rectum  unaided  by  the 
other  hand)  does  not  give  much  information  as  to  the  condition  of  the 
uterus. 

Where,  from  rigidity  of  the  abdominal  walls,  it  is  difficult  to  press 
down  or  fix  the  uterus  with  the  external  hand,  this  may  be  done  with 
the  volsella  in  the  vagina.  The  use  of  the  volsella  enables  us  to  draw 
the  uterus  better  within  reach  of  the  finger  in  the  rectum.  This  exami- 
nation per  rectum  aided  by  the  volsella  will  be  considered  in  the  next 
chapter. 

Of  all  manual  examinations  of  the  pelvis,  the  abdomino-rectal  or 
abdomino-vagino-rectal  is  the  most  thorough.  In  retroversions,  prolapsed 
ovaries,  and  pathological  anteflexion,  it  should  never  be  omitted.  A 
patient  may  object  to  it  and  refuse  to  allow  it ;  and,  of  course,  the 
practitioner  must  keep  this  in  mind. 


SIMON  S  METHOD  OF  PASSING  THE  HAND  INTO  THE  RECTUM. 

This  consists  in  passing  the  whole  hand  through  the  sphincter  ani  into 
the  rectum,  and  even  up  to  the  transverse  colon.  The  patient  is  deeply 
narcotized ;  the  hand  is  passed  cautiously  through  by  inserting  first  two 
fingers  and  the  others  successively  until  the  entire  hand  is  passed  ;  incision 
of  the  sphincter  ani  may  be  necessary.  Sometimes  an  incurable  incon- 
tinence of  faeces  has  resulted. 

The  unanimous  opinion  of  gynecologists  is  that  this  severe  method  of 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS.     109 

examination  is  unnecessary.     Careful  bimanual  examination,  aided  when 
necessary  by  anaesthetics,  gives  equally  good  results. 

For  specialists  it  is  of  use  to  know  that  valuable  results  in  minute  pre- 
cise rectal  examination  can  be  got  by  first  injecting  air  into  the  rectum. 
The  whole  rectum  up  to  the  sigmoid  flexure  can  be  dilated,  the  sphincters 
made  out  and  the  bony  pelvic  wall  carefully  explored.  It  is  necessary  to 
add,  however,  that  this  is  an  adjunct  to  the  rectal  method  of  examination 
of  use  only  in  certain  instances. 


CHAPTER  IX. 
THE    VOLSELLA. 

LITEBATUKE. 

GoodeU — Some  Practical  Hints  for  the  Treatment  and  the  Prevention  of  the  Diseases 
of  Women  :  Medical  and  Surgical  Reporter,  January,  1874.  Hegar — Zur  gynako- 
logischen  Diagnostik  :  Die  combinirte  Untersucbung,  Volkmanns  Sammlung,  No. 
105.  Simpson,  A.  Russell — The  Use  of  the  Volsella  in  Gynecology  :  Contributions 
to  Obstetrics  and  Gynecology,  p.  183. 

•  WE  have  already  seen  that  one  of  the  most  striking  anatomical  features 
and  properties  of  the  uterus  is  the  considerable  range  of  its  mobility  in 
almost  every  direction.  It  can  be  pushed  upwards  from  its  normal  posi- 
tion 1|  or  2  inches,  and  is  displaceable  forwards  or  laterally  in  a  very 
marked  degree.  If  laid  hold  of  with  the  instrument  known  as  a  volsella, 
it  can  be  drawn  downwards  (by  a  force  not  exceeding  five  or  six  pounds) 
until  the  os  externum  lies  close  to  the  vaginal  orifice.  This  procedure 
facilitates,  in  suitable  cases,  diagnosis  and  treatment  of  gynecology  so 
much  that  it  is  well  worthy  of  the  allotment  of  a  special  chapter  to  its  dis- 
cussion. We  take  up — 

1.  Description  of  instrument ; 

2.  Method  of  use  ; 

3.  Mechanism  of  the  displacement  it  causes  ; 

4.  Uses  ; 

6.  Contra-indications. 

1.  Description  of  Volsella. — At  Fig.  76  is  seen  the  useful  volsella  em- 
ployed by  Russell  Simpson.  As  it  is  generally  the  anterior  lip  of  the  cer- 
vix that  is  laid  hold  of,  the  slight  pelvic  curve  given  to  the  blades  is  un- 
necessary since  the  volsella  lies  along  the  straight  anterior  vaginal  wall. 
Fig.  77  shows  Hart's  volsella,  where  this  straightness  of  the  blades  qud 
the  vagina  is  secured,  and  the  handle  and  fingers  of  the  gynecologist  are 
kept  away  from  the  vaginal  orifice  by  the  bend  on  the  handle.  Every 
volsella  should  have  a  catch  on  it.  Sometimes  it  is  useful  to  have  an  in- 


EXAMINATION  OF  THE  FEMALE  PELVIC  OKGANS. 


Ill 


strument  whose  blades  pass  over  one  another,  so  as  to  separate  for  instance 
the  lips  of  a  split  cervix  :  such  is  Hank's  instrument. 


Professor  A.  R.  Simpson's  volsella,  with  catch. 

2.  Method  of  Use.     (a.)   Without  previous  passage  of  Speculum. — The 
patient  is  placed  in  the  ordinary  left  lateral  posture.     Two  fingers  of  the 


112 


MANUAL    OF    GYtfECOLOGY. 


right  hand  are  passed  into  the  vagina  and  the  anterior  lip  of  the  cervix 
touched.  The  volsella,  held  in  the  left  hand-,  is  guided  along  between  the 
index  and  middle  exploring  fingers  ;  the  anterior  lip  of  cervix  is  seized 
and  drawn  down.  Kectal  examination  is  now  made.  (6.)  With  the  Spec- 
ulum.— For  this,  see  Chapter  X. 

3.  Mechanism  of  Displacement  it  causes. — The  uterus  is  drawn  down  so 
as  to  lie  behind  the  symphysis  pubis.     If  drawn  down  fully,  as  it  may  be 


Dr.  Hart's  volsella. 


in  exceptional  cases,  it  has  its  long  axis  in  the  vagina  and  the  os  externum 
near  the  vaginal  orifice. 

The  vaginal  walls  are  inverted,  i.e.,  when  the  os  externum  is  at  the 
vaginal  orifice  we  have  a  deep  pouch  behind  and  in  front  of  the  uterus. 

The  relations  of  the  bladder  and  rectum  are  given  in  Fig.  78. 

4.  Uses,  (a)  In  Diagnosis.  —  (1.)  The  cervix  which  may  seem  "ulcerated," 
as  it  is  commonly  called,  is  easily  demonstrated  by  the  volsella,  to  be 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS.  113 

singly  or  doubty  lacerated.  For  this  purpose  tlie  anterior  and  posterior 
lips  are  laid  hold  of,  and  when  brought  together  the  ulceration  is  seen  to 
be  due  to  laceration  with  eversion. 

(2.)  Abdominal  tumours  can  be  shown  to  be  connected  with  the  uterus 
or  not  as  the  case  may  be.  If  the  patient  be  placed  in  the  dorsal  posture 
and  the  tumour  be  laid  hold  of  by  an  assistant,  then  when  the  uterus  is 
drawn  down,  the  tumour  can  be  felt  to  descend  if  fixed  to  it. 

(3.)  To  the  examination  per  rectum  the  volsella  is  a  valuable  addition. 
If  one  finger  be  placed  in  the  rectum,  and  the  cervix  laid  hold  of  with  a 
volsella  and  drawn  down,  the  mobility  of  the  uterus  can  be  estimated  ;  if 
it  be  anteflexed  by  cicatrized  utero-sacral  ligaments,  these  can  be  felt  tense 


Pig.  73. 

Mechanism  of  displacement  of  pelvic  floor  segments  when  volsella  is  used  (A.  E.  Simpson),    a,  symphysiu 
pubis  ;  6,  bladder  ;  c,  uterus ;  d,  perineum  ;  «,  rectum ;  /,  volsella. 

(Fig.  40) ;  the  whole  posterior  uterine  surface  may  be  palpated  for  small 
fibroids.  The  ovaries  are  made  more  accessible  ;  and  the  uterus,  especially 
if  small,  can  have  its  length  estimated  by  the  rectal  finger. 

This  method  of  examination  of  the  uterus  by  rectum  and  volsella, 
judiciously  conducted,  is  of  the  very  greatest  value. 

It  is  evident  that  it  will  also  help  one  as  to  the  diagnosis  of  displace- 
ments of  the  uterus  ;  but  its  value  in  this  respect  is  somewhat  lessened 
by  the  displacement  its  use  causes.  Thus  it  makes  a  retroversion  less 
retroverted  ;  an  anteflexion  less  anteflexed  ;  an  anteversion  less  anteverted. 

(6)  In  Treatment. — In  this  the  volsella  is  one  of  the  most  useful  instru- 
ments the  gynecologist  possesses.  Thus  it  helps  greatly  in  the  examina- 
VOL.  L— 8 


114  MANUAL    OF    GYNECOLOGY. 

tion  of  the  aborting  uterus  ;  in  replacement  of  the  gravid  or  non-gravid 
retroverted  uterus  ;  in  insertion  of  sponge  and  tangle  tents,  or  stem 
pessaries.  In  operations  such  as  Emmet's  for  repair  of  the  cervix,  Sims' 
division  of  the  cervix,  amputation  of  vaginal  portion  of  cervix,  excision  of 
the  uterus  through  the  vagina  for  cancer,  it  is  indispensable. 

Details  on  its  uses  in  these  cases  will  be  given  under  the  special  de- 
scriptions of  the  operations  ;  and  it  will  also  be  shown  in  the  chapter  on 
specula,  that  by  using  the  volsella  the  speculum  may  be  dispensed  with  in 
certain  cases. 

5.  Contra-indications. — It  should  not  be  used  in  acute  peritonitic  or 
cellulitic  attacks,  in  distended  Fallopian  tubes,  in  hsematocele  or  in  ad- 


1 


Fig.  79. 
*  Sims'  tenaculum. 


vanced  cancerous  disease.     No  pain  should  be  caused  by  its  uge  provided 
that  only  the  vaginal  aspect  of  the  cervix  is  laid  hold  of. 

The  amount  of  traction  to  be  made  will  vary  with  the  necessities  of  the 
case.  In  many  instances  only  a  mere  steadying  action  is  requisite  ;  in 
others  the  cervix  has  to  be  drawn  half-way  down  the  vagina.  In  special 
cases  the  cervix  is  drawn  down  to  the  vaginal  orifice  or  beyond  it,  as  in 
amputation  of  the  cervix  or  excision  of  the  uterus.  For  simply  steadying 
the  cervix,  Sims'  tenaculum  is  of  service  (Fig.  79). 


CHAPTER  X. 
VAGINAL  SPECULA. 

LITERATURE. 

Barnes — Op.  cit.  Goodell — Op.  cit.  Hart — Structural  Anatomy,  op.  cit.  Munde — Op. 
cit.  Sims,  J.  Marion — Clinical  Notes  on  Uterine  Surgery  :  Hardwicke  &  Co. , 
London,  1866.  Thomas— Op.  cit. 

WE  have  already  seen  that  the  segments  of  the  pelvic  floor  are  separable 
when  a  woman  assumes  certain  postures  ;  that  the  sacral  segment  can  be 
hooked  up,  and  that  by  this  means  we  get  a  view  of  the  vaginal  boundaries 
of  these  segments  and  of  the  os  uteri.  This  is  the  natural  method  of 
opening  up  the  pelvic  floor  ;  or  the  natural  specular  method. 

Gynecologists  had  used  various  instruments  for  enabling  them  to  look 
into  the  vagina  ;  but  all  of  these  proved  unsatisfactory  until  Marion  Sims, 
noting  the  natural  postural  dilatation  of  the  vagina,  introduced  his  famous 
duckbill  speculum. 

We  take  up  the  consideration  of  four  typical  specula,  viz.  : — 

1.  The  duckbill,  or  Sims  speculum, 

2.  The  tubular,  or  Fergusson  speculum. 

3.  The  Neugebauer  and  its  modifications, 

4.  The  bivalve  of  Cusco. 

We  note  under  each  its  nature,  the  method  of  employing  it,  and  the 
theory  of  its  action  and  uses. 

1.  The  SIMS  or  DUCKBILL  SPECULUM  is  shown  at  Figs.  80,  81,  and  Plate  V. 

Its  Nature. — Each  instrument  in  reality  consists  of  two  specula,  which 
are  of  different  size  and  connected  by  a  handle  ;  usually,  however,  we  speak 
of  these  specula  as  the  blades  of  the  speculum.  The  real  Sims'  speculum 
is  light,  has  each  blade  slightly  concave  on  its  anterior  aspect,  and  has  the 
blades  at  right  angles  to  the  intermediate  handle. 

Modifications  of  Sims'  speculum  are  numerous.  Indeed  it  seems  dif- 
ficult for  gynecologists  to  resist  modifying  an  instrument,  and  very  ram 


116  MANUAL    OF    GYNECOLOGY. 

to  find  them  improving  it.  The  most  widely  known  modification  is 
Bozeman's  ;  it  is  heavier  than  Sims',  has  the  blades  meeting  the  handle  at 
an  acute  angle,  and  the  blades  more  concave  on  the  anterior  aspect. 
(Figs.  81  and  82.) 

One  curious  fact  about  almost  all  specula  is,  that  they  are  too  long. 


Fig.  80. 
Sims'  Bpeculum. 


Sims'  blade  is  4  inches  long,  though  the  posterior  vaginal  wall  measures 
only  3£  inches.  Thus,  as  we  wish  to  expose  only  the  anterior  vaginal  wall 
and  cervix  uteri,  a  3-inch  length  of  blade  is  sufficient. 

A  modification  of  Sims'  speculum,  by  Dr.  Battey  of  Georgia,  is  worthy 


Fig.  81.  Fig.  82. 

Sims'  speculum.  Sims'  speculum  modified  by  Bozeman. 

of  note.     It  has  one  short  blade  which  meets  the  handle  at  a  more  acute 
angle.     (Fig.  83.) 

The  Method  of  employing  Sims'  Speculum. — Under  this  it  is  important 


Fig.  83. 
Battey's  speculum. 


to  note  :  (a)  How  to  place  the  patient,  (b)  How  to  pass  the  speculum,  and 
(c)  How  to  hold  it  when  passed. 

(a.)  How  to  place  the  Patient. — The  patient  must  be  placed  in  the  Sims 


PLATE  V 


cc  a 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS.  117 

or  in  the  semiprone  posture.  This  is  briefly  as  follows.  The  patient  lies 
almost  on  the  breast :  the  lower  left  arm  is  over  the  edge  of  the  couch  next 
the  gynecologist :  the  hips  are  close  to  the  edge  :  the  knees  are  well  drawn 
up ;  and  the  upper  or  right  knee  touches  the  couch  with  its  inner  aspect.  The 
posterior  aspect  of  the  sacrum 'is  therefore  oblique  to  the  horizon.  (Plate 
IV.) 

As  the  result  of  this  posture — a  modified  genu-pectoral  one — the  vaginal 
walls  separate  when  air  is  admitted  ;  the  pubic  segment  passing  down 
with  the  viscera,  the  sacral  one  remaining  behind. 

(6.)  How  to  pass  the  Speculum. — Choose  the  blade  which  is  of  the  proper 
size  to  pass  the  vaginal  orifice  ;  warm  it,  and  oil  it  with  the  fingers  on  its 
convex  aspect  only.  The  concave  surface  must  be  dry  to  reflect  light,  and 
therefore  the  speculum  should  never  be  oiled  by  dipping  it.  Hold  it  by 


Fig.  84. 
One  method  of  holding  Sims'  speculum. 

the  other  blade  in  the  left  hand,  as  shown  at  Fig.  84.  Then  pass  the 
index  and  middle  fingers  of  the  right  hand  into  the  vagina  to  separate  the 
labia  ;  carry  in  the  speculum  between  them  ;  push  it  onwards,  following 
the  curve  of  the  posterior  vaginal  wall,  until  the  beak  of  the  instrument 
lies  on  the  posterior  fornix.  Now  draw  the  instrument  back  as  a  whole, 
in  a  direction  at  right  angles  to  the  posterior  vaginal  wall ;  then  turn  the 
beak  forwards,  so  as  to  bring  the  cervix  more  into  view.  Finally  tilt  the 
blade,  so  that  the  beak  lies  on  a  lower  level  than  the  proximal  end  of 
the  blade  :  this  keeps  up  the  upper  labium. 

(c.)  How  to  hold  the  Speculum  when  passed. — Plate  V.  shows  the  specu- 
lum passed,  and  a  convenient  way  of  holding  it.  "When  passed,  the  cervix 
may  be  drawn  down  with  a  volsella  (also  shown  in  Plate  V.).  Various  at- 
tempts have  been  made  to  add  to  the  Sims  speculum  a  means  of  render- 
ing it  self-sustaining  ;  the  majority  of  these  are  by  no  means  successful, 
and  therefore  we  need  not  describe  what  is  seldom  used.  The  knowledge 


118  MANUAL    OF    GYNECOLOGY. 

of  a  simple  method  of  effecting  this  in  Battey's  speculum  is  of  use.  This 
has  a  piece  of  indiarubber,  with  a  hook  at  the  end  attached  to  the  handle, 
which  can  be  fastened  in  the  pillow,  sheet,  or  patient's  dress ;  the  cervix 
is  drawn  down  with  a  volsella  held  in  one  hand,  leaving  the  other  free  for 
minor  manipulation. 

Theory  of  Action  and  Uses  of  the  Sims  Speculum. — The  Sims  speculum 
is  based  on  the  effects  consequent  on  the  genu-pectoral  posture.  When 
the  patient  is  semiprone  and  the  vaginal  orifice  opened,  the  segments  of 
the  pelvic  floor  separate  ;  and  then  the  Sims  speculum  is  a  simple  means 
of  hooking  the  sacral  segment  well  back. 

The  Sims  speculum  is,  on  the  whole,  by  far  the  most  useful  speculum. 
It  is  difficult  to  manipulate  at  first,  but  amply  repays  practice.  Its  dis- 
covery has  been  one  of  the  greatest  strides  in  gynecology.  In  vaginal  and 
cervical  operative  surgery,  it  is  the  only  speculum  that  can  be  used. 

2.  The  FEKGUSSON  SPECULUM  is  seen  at  Fig.  85.     It  is  made  in  three 


Fergusson  speculum. 

suitable  sizes  ;  and  may  be  described  as  a  glass  .tube,  with  a  proximal 
trumpet  and  a  distal  bevelled  end.  It  is  made  of  glass  silvered  internally 
and  coated  on  the  outside  with  caoutchouc.  The  bevelling  of  the  distal 
end  makes  a  shorter  anterior  side  and  a  longer  posterior  one.  The 
maker's  name  is  usually  placed  at  the  trumpet  end  just  at  the  foot  of  the 
anterior  side,  and  serves  to  indicate  that  side  when  the  speculum  is  in  the 
vagina. 

Mode  of  Employment  of  the  Fergusson  Speculum.— The  patient  lies  in 
the  left  lateral  position  with  hips  raised.     Warm  the  speculum,  and  oil  it 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS.     119 

on  the  outside.  Take  it  by  the  trumpet  end  with  the  light  hand  and 
pass  it  into  the  vaginal  orifice  previously  opened  up  by  index  and  middle 
fingers  of  the  left ;  now  push  it  in,  short  side  to  the  front,  until  arrested. 
By  looking  along  it,  the  practitioner  can  note  if  the  cervix  is  in  view.  It 
is  generally  not  so,  but  may  be  snared  by  the  following  manoeuvres ; 
carry  the  trumpet  end  well  back  towards  the  perineum  and  then  depress 
the  distal  end  first  to  the  left  and  then  to  the  right,  finally  turning  it 
round  if  these  fail.  In  multiparse  with  lax  vaginae  it  is  easy  to  pass  the 
Fergusson  ;  but  it  is  more  difficult  in  nulliparse. 

The  Fergusson  is  a  favorite  speculum  with  many.     It  is  useless  in 


o 

Fig.  87. 

Cross  section 
showing  relation 
of  blades :  the 
upper  is  poste- 
rior. 


Fig.  8fi. 
Neugebauer's  upeculuin  when  passed. 

vaginal  and  cervical  surgery,  but  with  it  applications  to  the  cervix  can  be 
made  very  well  and  easily.  When  used  for  making  applications  to  the 
endometrium,  it  is  advisable  to  pull  the  cervix  well  down  with  a  volsella 
after  the  speculum  is  passed,  and  to  use  a  straight  sound  covered  with 
cotton  wool. 

3.  The  NEUGEBAUEB  is  like  a  Sims  speculum  divided  transversely  at  the 
middle  of  the  handle  (Fig.  86).  It  is  also  made  in  suitable  sizes. 

Mode  of  Employment. — Warm  and  oil  two  blades.  Introduce  one  blade 
(the  broader  one)  with  its  convexity  touching  the  posterior  vaginal  wall 


120 


MANUAL    OF    GYNECOLOGY. 


Then  introduce  the  other  with  its  convexity  touching  the  anterior  vaginal 
wall  and  so  that  its  edges  fit  within  the  edges  of  the  posterior  vaginal 


Fig.  88. 
Barnes'  crescent  speculum. 

wall  blade   (Fig.  87).     The  beak  of  the  posterior  blade  is  thus  in  the 
posterior  fornix  ;  that  of  the  anterior  blade  in  the  anterior  fornix.     From 


Fig.  89. 
Cusco's  speculum. 

their  contact  a  leverage  is  obtained  on  separating  the  handles,  by  which 
traction  is  made  on  the  fornices  and  the  cervical  canal  more  or  less 
everted. 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS.  1  '2  [ 

Fig.  88  shows  a  useful  modification  of  this  by  Barnes,  known  as  the 
Orescent  speculum. 

The  Neugebauer  and  Crescent  specula  are  useful  in  making  cervical 
and  endometric  applications,  and  are  better  specula  than  the  Fergusson. 

4.  The  Cusco  or  BIVALVE  SPECULUM  is  shown  at  Fig.  89.  It  is  composed 
of  two  blades  jointed  qn  to  one  another  at  their  bases.  The  blades  are 
opened  to  the  desired  distance  by  pressure  on  the  thumb-piece  and  kept 
open  by  a  screw.  It  is  introduced  with  its  blades  right  and  left  and  then 
turned  so  that  they  lie  anterior  and  posterior,  that  with  the  screw  being 
posterior.  It  is  then  pushed  onwards,  and  the  blades  opened  and  fixed  by 
the  screw. 

Care  should  be  taken  not  to  catch  any  of  the  perinea],  hairs  in  the 
screw  ;  and,  in  withdrawing  it,  not  to  pinch  up  the  vaginal  walls. 

The  Cusco  speculum  is  self-retaining  and  useful  in  cervical  and  en- 
dometric applications. 

If  the  patient  he  placed  in  the  yenu-pectoral  or  semiprone  posture,  the 
posterior  cayinal  wall  hooked  back  with  the  finger  and  the  cervix  drawn  down, 
with  a  eolsella,  a  useful  ciev;  can  be  obtained  without  the  aid  of  any  speculum. 

USES    AND    COMPARATIVE    VALUE    OE    THE    VARIOUS    SPECULA. 

The  Sims  is  undoubtedly  the  best  and  most  scientific  speculum  we 
possess.  'When  properly  used  and  aided  by  the  volsella,  it  leaves  nothing 
to  be  desired.  For  operative  cases  its  use  is  imperative  ;  and  it  is  the 
only  speculum  which  does  not  distort  the  split  cervix.  It  is  objected  by 
some — on  insufficient  grounds  —that  it  is  difficult  to  manipulate,  requires 
a  skilled  assistant,  and  exposes  the  patient  unduly. 

The  Fergusson  is  easily  passed,  involves  only  slight  exposure,  and  is 
good  in  very  minor  gynecology.  It  gives  only  a  limited  view  of  the 
vaginal  walls.  The  student  should  note  that  it  brings  the  tlaps  of  a  split 
cervix  together  and  somewhat  conceals  the  lesion. 

The  Neugebauer,  on  the  other  hand,  opens  up  the  cervical  split,  and 
may  do  this  so  effectually  as  to  give  the  impression  that  there  is  none. 
The  Fergusson,  Cusco,  and  Neugebauer  are  all  s'-lf-retaininy. 


CHAPTER  XI 

THE  UTEEINE  SOUND. 

• 

LITERATURE. 

Simpson,  Sir  J.  T. — Memoir  on  the  Uterine  Sound,  Selected  Obst.  Works  :  A.  &  C. 
Black,  Edinburgh,  1871.  See  Mund&s  Minor  Gynecology  and  Thomas  as  to 
Huguier  &  Lair. 

IK  considering  this  important  gynecological  instrument,  we  take  up— 

1.  Its  nature : 

2.  Preliminaries  to  its  use  ;  when  not  to  use  it : 

3.  Method  of  use  ;  difficult  cases  : 

4.  Employment  for  diagnosis  and  treatment : 

5.  Dangers  attending  its  use  : 

6.  Relation  to  bimanual  and  rectal  examination. 

NATURE. 

The  sound  of  Sir  James  Simpson  is  not  only  the  classical  instrument, 
but,  taken  all  in  all,  is  probably  the  best.  We  describe  it,  therefore,  as  a 
type  of  the  instrument,  and  then  consider  its  modifications. 

Simpson's  sound  is  a  rod  of  flexible  metal  12  inches  long,  specially 
graduated  and  provided  with  a  suitable  handle  (Fig.  90).  It  is  made  of 
copper,  nickel-plated  ;  this  is  sufficiently  pliable  to  be  moulded  and  yet 
sufficiently  stiff  to  retain  any  special  shape  given  to  it.  Instrument-makers 
often  make  this  sound  too  unyielding.  It  should  be  always  pliable  enough 
to  be  bent  with  two  fingers. 

The  handle  has  the  shape  shown  at  Fig.  91.  Note  that  it  is  roughened 
on  the  same  side  as  that  towards  which  the  point  of  the  instrument  lies. 
Consequently,  when  the  sound  is  in  the  uterus,  we  can  tell  the  direction 
of  the  point  by  noting  this  roughness  on  the  handle. 

The  graduation  is  important.  2|  inches  from  the  point  is  a  rounded 
knob  :  this  is  the  length  of  the  fully  developed  unimpregnated  uterine 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS. 


123 


cavity.  Other  markings  are  at  3  inches,  4£  inches,  5£  inches,  and  so  on 
up  to  8£  inches.  The  notch,  1^  inch  from  the  point,  is  of  little  use  and 
weakens  the  instrument. 

The  modifications  of  this  instrument  are  numerous.  The  changes  are 
chiefly  in  its  flexibility,  lightness,  and  in  the  use  of  another  material. 

Prof.  A.  Russell  Simpson  has  modified  the  instrument  by  making  it 


Fig.  90. 
Sir  J.  Y.  Simpson's  sound.    The  1%  in.  notch  is  not  shown,    a,  ly,  in.  knob. 

shorter,  abolishing  the  1|  inch  notch,  and  squaring  the  handle  (Fig.  91) : 
this  gives  a  very  handy  and  useful  instrument.  Sims,  Emmett,  and 
Thomas  have  each  a  special  sound.  Thomas'  is  made  of  hard  rubber  or 


Fig.  91. 
Russell  Simpson's  sound. 

whalebone,  and  he  claims  that  it  is  specially  useful  in  the  case  of  sub- 
mucous  fibroids.  Other  modifications  are  by  Mathews  Duncan,  Protheroe 
Smith,  Aveling,  Jennison,  Hanks,  &c. 


PRELIMINARIES  TO  ITS  USE. 

No  instrument  should  have  the  preliminaries  to  its  use  more  care- 
fully considered.  The  rash  and  careless  use  of  the  sound  may  do  immense 
mischief  to  the  patient.  Note  then  when  not  to  use  it  : 

(1.)  The  sound  is  not  to  be  passed  during  an  ordinary  menstrual 

period. 
(2.)  It  is  not  to  be  passed  in  an  acute  inflammatory  attack  of  uterus, 

ovaries,  pelvic  peritoneum,  or  connective  tissue. 
(3.)  It  is  not  to  be  passed  in  cases  of  cancer  of  the  cervix  or  body 
of  the  uterus. 


124 


MANUAL    OF    GYNECOLOGY. 


(4.)  It  is  not  to  be  passed  if  the  patient  has  missed  a  menstrual 
period.     This  is  a  safe  rule,  but  admits  of  limitation  as  we 
shall  see  afterwards. 
Before  using  it — 

(1.)  Ascertain  that  the  patient  has  not  missed  a  period. 

(2.)  Do  the  bimanual  carefully.     If  in  doubt,  use  the  rectal  exam- 
ination aided  by  the  volsella. 

(3.)  Place  the  patient  in  the  left  lateral  posture. 

(4. )  Give  the  sound  the  curve  you  find  the  uterus  to  have. 


METHOD    OF   USE. 


After  the  preliminaries  mentioned  above,  take  the  sound  in  the  hand 
and  oil  its  first  3  inches  with  carbolic  oil  1-20.     Pass  the  two  fingers  of 


Fig.  92. 
First  stage  of  passing  the  sound. 


the  right  hand  into  the  vagina  and  touch  the  anterior  lip  of  the  cervix, 
•i.e.,  in  front  of  the  os.     Guide  the  sound  along  the  vaginal  fingers  and 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS.  125 

make  the  point  enter  the  os  uteri  (Fig.  92).     Pass  it  in  for  an  inch  or  so, 
to  fix  it. 

If  the  uterus  be  retroverted  then  carry  the  handle  towards  the  symphy- 
sis,  when  the  point  of  the  instrument  will  glide  into  the  uterine  cavity 
until  arrested  by  the  fundus  (Fig.  93).  No  force  is  needed.  If  force 


Fig.  93. 

Second  stage  of  passing  the  sound  when  uterus  is  retroverted. 

seems  necessary,  the  instrument  should  be  withdrawn  and  a  more  careful 
bimanual  performed. 

If  the  uterus  lie  to  the  front,  the  procedure  is  different.  Pass  the  sound 
as  already  described  until  it  has  entered  the  cervix  for  an  inch  or  so  (Fig. 
92).  Note  now  that  the  point  of  the  sound  looks  back,  whereas  the 
fundus  lies  to  the  front.  Clearly  we  must  make  the  point  look  to  the 
front.  This  is  done  by  turning  the  handle  so  that  the  roughened  surface 


126 


MANUAL    OF    GYNECOLOGY. 


looks  to  the  front.     To  do  this  we  do  not  twist  round  the  handle  on  its 
long  axis,  but  make  it  sweep  round  the  arc  of  a  wide  semicircle  as  in  Fig. 


Pig.  94. 
a,  Proper  method  of  turning  the  sound,  contrasted  with  improper  method,  6. 

94.  The  point,  during  this  manoeuvre,  remains  fixed  or  nearly  so.  Now 
carry  the  handle  back  to  the  perineum  when  the  point  glides  into  the 
cavity  (Fig.  95). 


Fig.  95. 
Second  stage  of  passing  the  sound  when  uterus  is  to  the  front. 

Another  way  of  passing  the  sound,  when  the  uterus  lies  to  the  front  is 
as  follows.     Place  the  patient  well   across  the  bed.     Do  bimanual  and 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 


127 


curve  sound  appropriately.  Take  the  sound  in  the  right  hand.  Pass  two 
fingers  of  the  left  hand,  palmar  surface  forward,  into  the  vagina  and  touch 
the  posterior  lip  of  the  cervix.  Carry  the  sound,  point  looking  forwards, 
into  the  vagina  ;  make  it  enter  the  os  and  then  carry  the  handle  towards 
the  perineum,  when  the  point  will  glide  on.  This  method  avoids  the 


Fig.  %. 

Sound  arrested  (before  rotation)  in  a  case  of  antcflexion. 

sweeping  round  of  the  handle,  and  is  useful  if  the  uterus  is  very  much 
anteverted. 

The  sound  may  be  passed  after  the  uterus  is  drawn  down  with  a  vol- 
sella,  or  after  the  Sims  speculum  has  been  introduced. 

Difficult  Cases. — These  are  chiefly  found  in  markedly  anteflexed  uteri. 


128  MANUAL    OF    GYNECOLOGY. 

The  sound  passes  in  so  far  (Fig.  96),  but  when  turned  has  its  point  look- 
ing too  directly  upwards.  In  such  cases  first  draw  the  cervix  down  with 
a  volsella,  now  pass  the  sound,  and  should  it  still  stop  at  the  flexion  make 
pressure  with  a  finger  in  the  anterior  foruix  to  push  up  the  fundus.  Then 
get  an  assistant  to  carry  the  handle  of  the  sound  towards  the  perineum. 

When  the  uterine  cavity  is  tortuous,  as  in  submucous  fibroids,  a  gum 
elastic  bougie — No.  10 — may  be  used  to  ascertain  the  length  of  the 
uterine  cavity.  Thomas',  Jennison's,  or  Emmet's  sound  is  specially  useful 
here. 

EMPLOYMENT    OF    THE    SOUND    FOR   DIAGNOSIS    AND    TREATMENT. 

(A)  DIAGNOSIS. 

(1. )  Length  of  uterine  cavity.  This  varies  in  different  pathological  con- 
ditions. Thus  the  cavity  is 

(a)  lessened  in  Superinvolution  of  uterus, 

Atrophic  uteri ; 

N.B. — The  sound  easily  perforates  the  thinner  wall 
of  the  superinvoluted  uterus.  This  does  no 
harm.  It  may  also  pass  along  the  Fallopian 
tube. 

(6)  increased  in  Subinvolution  of  uterus, 
Hypez'trophy  of  uterus, 
Cervical  hypertrophy, 
Endometritis, 

* 

Submucous  fibroids, 
Interstitial  fibroids, 
Small  uterine  polypi, 
Prolapsus  uteri. 

(2. )  Direction  of  uterine  axis  ;  whether  retroverted,  anteverted,  lateri- 
verted. 

(3. )  Relation  of  axis  of  uterine  body  to  that  of  cervix,  whether  we  have 
anteflexion  or  retroflexion. 

(4. )  Stenosis  and  atresia  at  os  internum  and  os  externum ;  tenderness  of 
fundus,  as  in  endometritis. 

(5.)  Mobility  of  uterus.  This  should  be  ascertained  in  the  following 
way.  Pass  the  sound  as  already  described.  Make  the  patient  turn  on  her 
back,  and  then  place  two  fingers  in  the  vagina,  palmar  surface  upwards,  and 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS.  129 

touching  the  posterior  lip  of  the  cervix.  The  sound  lies  on  the  palm  of 
the  hand,  is  steadied  with  the  thumb,  and  can  be  used  to  move  the  uterus 
gently  about  as  desired.  When  the  uterus  is  not  easily  denned  by  the 
upper  hand  in  the  bimanual,  the  sound,  passed  and  used  as  just  indicated, 
enables  the  upper  hand  to  map  it  out  better.  Prof.  A.  Kussell  Simpson's 
sound  is  specially  useful  for  this  manoeuvre,  as  the  shortness  of  the  stem 
and  the  form  of  the  handle  allow  the  latter  to  lie  flat  on  the  palm. 

(6. )  Rough  condition  of  endometrium  ;  often  associated  with  bleeding 
when  sound  is  passed. 

(7.)  Differential  diagnosis  between  uterine  polypi  projecting  into  vagina, 
and  inverted  uterus,  etc. — When  we  have  a  polypus  to  deal  with,  the  sound 
passes  in  through  the  cervix  for  more  than  the  usual  distance  because  the 
uterine  cavity  is  enlarged.  In  inversion  it  passes  for  only  a  short  distance 
into  the  cervix,  and  is  then  stopped  by  its  reflexion.  Sometimes,  however, 
the  neck  of  the  polypus  is  adherent  all  round  to  the  cervical  canal,  thus 
simulating  inversion  ;  and  in  some  very  rare  cases  the  mucous  membrane 
of  the  uterus  becomes  separated  and  expelled  from  the  uterine  cavity, 
simulating  inversion  of  the  whole  uterus,  owing  to  the  separation  stopping 
at  the  os  internum.  It  is  evident  that  in  these  last  two  cases  the  bimanual 
clears  up  the  diagnosis,  the  upper  hand  feeling  the  body  of  the  uterus  in 
its  normal  position  in  both  of  them.  The  sound  is  only  confirmatory  of 
the  bimanual. 

(B)  TREATMENT. 

(1.)  Rectification  of  undue  angular  relation  between  the  uterine  body  and 
cervix  (anteflexion,  retroflexion) :  dilatation  of  uterine  canal  as  a  whole,  or  of 
stricture  at  os  internum. 

(2.)  Replacing  of  retroverted  unfixed  uterus. 

(3.)  Application  of  acids  to  endometrium  on  the  sound  covered  with  cotton 
wool. 

DANGERS    ATTENDING   ITS   USE. 

The  great  dangers  to  the  patient  from  the  passage  of  the  uterine  sound 
are  abortion  and  abrasion  of  the  mucous  membrane,  with  absorption  of 
septic  matter  and  resulting  pelvic  cellulitis  or  peritonitis. 

The  former  untoward  result  must  be  very  carefully  guarded  against. 
One  valuable  caution  is  never  to  omit  the  question  as  to  the  menstruation, 

and  to  ask  if  it  was  the  usual  amount.    Some  women  have  a  slight  discharge 
VOL.  I.— 9 


130  MANUAL    OF    GYNECOLOGY. 

of  blood  at  the  first  period  after  they  conceive,  some  even  menstruate  dur- 
ing the  whole  period  of  utero-gestation.  The  bes£  safeguard  is  the  careful 
performance  of  the  bimanual.  This  soon  teaches  the  practitioner  to  know 
whether  he  has  an  unimpregnated  uterus  between  his  hands,  or  one  at  the 
second  or  third  month  of  gestation.  Special  care  should  be  taken  when 
the  uterus  is  retroverted  :  it  may  be  also  gravid  ;  and  the  pregnancy  may, 
by  causing  pressure,  have  induced  the  patient  to  consult  a  medical  man. 
As  the  bimanual  is  often  difficult,  an  unwary  use  of  the  sound  may  make 
the  diagnosis  disagreeably  evident. 

The  means  to  avoid  setting  up  any  inflammatory  disturbance  are — to 
perform  the  bimanual  carefully,  to  curve  and  oil  the  sound  properly,  and 
to  pass  it  gently. 

SOUND   COMBINED   WITH    BIMANUAL. 

The  importance  of  this  method  of  examination  has  been  recently 
pointed  out  by  Professor  A.  Kussell  Simpson,  in  a  paper  read  to  the  Edin- 
burgh Obstetrical  Society.  For  its  performance  the  short  sound  with 
the  square  handle  (Fig.  91)  is  necessary.  It  is  of  such  a  length  that, 
when  the  middle  finger  is  at  the  knob,  the  flat  surface  of  the  handle  rests 
on  the  ball  of  the  little  finger,  against  which  it  is  steadied  by  the  flexed 
little  and  ring  fingers. 

The  sound  is  introduced  into  the  uterus  in  the  ordinary  way.  The 
fingers  are  passed  into  the  vagina  as  for  a  vaginal  examination,  and  the 
sound  grasped  as  in  Fig.  97.  The  thumb  rests  on  the  symphysis  pubis. 
While  the  middle  finger  steadies  the  sound,  the  index  is  in  the  anterior 
fornix,  and  the  external  hand  placed  as  in  the  ordinary  bimanual. 

This  method  is  specially  useful  (a)  when  the  uterus  is  flaccid ;  the 
sound  stiffens  it,  and  enables  the  external  hand  to  define  it :  (b)  when, 
from  the  presence  of  small  fibroids  or  pelvic  deposits,  there  is  doubt  as 
to  what  is  the  fundus  uteri ;  the  sound,  felt  by  the  external  hand  in  the 
uterus,  indicates  the  fundus. 

RELATION    OF    SOUND   TO   BIMANUAL    AND   RECTAL   EXAMINATION. 

Before  Sir  James  Simpson  introduced  the  use  of  the  sound,  gyneco- 
logical examination  was  confined  to  the  exploration  of  the  vagina  and 
cervix. 

Simpson  gave  an  immense  impulse  to  gynecology  by  placing  in  the 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS. 


131 


hands  of  gynecologists  an  instrument  which  explored  the  uterine  cavity 
above  the  cervix,  and  thus  enabling  them  to  obtain  a  perfection  of  diagno- 
sis before  undreamt  of ;  thus  gynecological  examination  was  made  up  of  a 
vaginal  examination,  and  then  a  passage  of  the  sound,  due  attention 
being  given  to  the  non-existence  of  pregnancy.  J.  Y.  Simpson  recom- 


Fig.  97. 

Sound  combined  with  bimanual  examination. 

mended,  further,  the  elevation  of  the  uterus  with  the  sound,  and  its  defi- 
nition with  the  upper  hand. 

The  next  step  in  gynecology  was  the  use  of  the  two  hands — the  bi- 
manual and  rectal  examinations — which  in  the  last  twenty  years  has 
developed  immensely.  Consequently,  the  use  of  the  sound  has  become 
more  limited.  The  teaching  in  this  chapter  has  been  based  on  a  recogni- 
tion of  this  fact,  inasmuch  as  the  use  of  the  sound  is  recommended  only 
after  the  bimanual,  rectal,  and  volsellar  examinations  have  been  carefully 
employed. 


CHAPTER    XII. 
THE  SPONGE  TENT  AND  OTHEE  UTEBINE  DILATOES. 

LITERATURE. 

Simpson,  J.  T. — Op.  cit.     Sims,  J.  M.—Op.  cit.     Landau — Ueber  Erweifcerungsmittel 
der  Gebiirmutter :  Volkmann's  Sammlung  No.  187.    Munde — Op.  cit. 

HITHERTO  we  have  considered  only  the  means  which  have  placed  the 
vagina  and  cervix  within  range  of  digital  examination.  In  this  section  we 
take  up  the  methods  by  which  we  get  digital  examinations  of  the  uterine 
cavity — methods  of  the  highest  practical  value,  which,  like  the  sound,  we 
owe  to  the  genius  of  Sir  James  Simpson. 
We  therefore  consider — 

I.    Means  of  slowly  dilating   the    Cervical    Canal   by  Sponge   Tents, 

Tangle  Tents,  Tupelo  Tents; 
IE.  Means  of  slowly  dilating  the  Cervical   Canal  by  graduated  hard 

rubber  Dilators — Tail's,  Hank's  ; 

HI.    Means  of  dilating  the  Cervical  Canal  by  incision  and  screw  Di- 
lators ;  this  last  will  be  described  under  Sims'  operation  for 
pathological  anteflexion. 
Under  each  we  take  up — 

1.  Material  or  instrument, 

2.  Purposes  for  which  used, 

3.  Preliminaries  to  and  method  of  use, 

4.  Dangers  and  contra-indications  to  use. 

DILATATION   BY    SPONGE,    TANGLE,    AND    TUPELO    TENTS. 

1.  Material.  —  The  sponge  tent  is  a  cone  of  good,  unbroken,  thor- 
oughly dried  sponge,  impregnated  with  some  antiseptic  and  then  firmly 
compressed  into  small  transverse  bulk,  its  original  length  being  preserved. 
When  thus  prepared  and  placed  under  conditions  where  it  can  absorb 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS. 


133 


moisture,  it  swells  up  and  in  thus  expanding  dilates  any  dilatable  struc- 
ture which  may  grasp  it. 

Good  sponge  tents  of  various  sizes  may  be  had  from  all  chemists.  In 
order  to  prevent  the  antiseptic  from  volatilizing,  the  sponge  tents  are  cov- 
ered with  grease.  They  are  provided  with  a  tape  at  the  base  to  aid  their 
extraction  from  the  cervix  after  use. 

Tents  are  also  made  from  the  ordinary  sea  tangle  (laminaria  digitata) 
(Fig.  98)  and  from  tupelo  wood  (nyssa  aquatilis).  It  is  alleged  that  the 


Fig.  98. 

Shows  on  the  left  a  slraight  and  a  curved  laminaria  tent  and  on  the  right  these  tents  alter  expansion. 
Note  how  one  has  been  gripped  by  the  os  internum  (Mnnde). 

tupelo   extends   more   rapidly   than   either   tangle   or   sponge.     Fig.  99 

shows   its   power   in   this  respect.     Tangle   tents   may  be   had  hollow; 

this  facilitates  the  imbibition  of  moisture  but  weakens  their  expanding 

powers. 

2.  Putposes  for  which  used. — Sponge  tents  are  used  as  follows  : 

(1.)  To  restrain  hemorrhage  in  cases  of  abortion  and  at  the  same  time 

dilate  the  cervix  for  further  interference  ; 


134 


MANUAL    OF    GYNECOLOGY. 


(2.)  To  dilate  the  cervix  and  uterine  cavity  and  enable  the  practitioner 
to  ascertain  and  remove  the  cause  of  pathological  uterine  hemorrhage, 
whether  due  to  endometritis,  sarcomata,  polypi,  or  incomplete  abortion ; 


Fig.  99. 

Diagram  to  show  relations  between  size  of  tupelo  tent,  before  and  after  expansion.     The  dotted  outside 
line  indicates  the  size  of  the  tent  after  expansion  (Mund6). 

(3.)  To  correct  pathological  flexions  of  the  uterus,  to  dilate  a  steno:ed 
cervix. 

Tangle  and  Tupelo  tents  have  the  same  scope  as  the  sponge  tent. 


Fig.  100. 
Expanded  tnpelo  tent  with  constriction  at  os  internum  (Mnnd6). 

These  do  not,  however,  expand  so  well  and  thoroughly.  Their  special  ad- 
vantages are  due  to  their  smaller  size,  and  the  fact  that  several  may  be 
passed  into  the  same  cervix.  They  are  specially  useful,  therefore,  in 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 


135 


cases  of  narrow  cervix  and  flexions     Tupelo  tents  are  highly  praised  by 
Landau  and  Munde,  but  are  still  on  trial. 

3.  Preliminaries  to  and  Method  of  Use. — Tents  should  not  be  passed 
during  an  ordinary  menstrual  period,  although  they  often  require  to  be 
used  when  pathological  bleeding  is  going  on.  They  should  always  be 
passed  at  the  patient's  own  house  ;  and  she  should  be  kept  strictly  in  bed 
during  their  use,  and  for  some  time  after.  Before  their  usen  the  vagina 
should  be  thoroughly  washed  out  with  warm  carbolic  lotion  (1-40). 
Schultze,  in  passing  tangle  tents  for  flexions,  first  ascertains  the  uterine 
curve  with  the  sound  ;  if  blood  follows  its  use,  he  postpones  the  introduc- 


Efo  101. 

Sponge  tent  polypus  of  Sir  James  Simpson  (>/,).  The  figure  shows  a  drawing  of  the  uterus,  which  con- 
tained a  polypus — obtained  from  a  patient  of  Sir  James  Simpson's,  who  died  from  the  hemorrhage  it 
caused.  It  was  this  preparation  which  suggested  to  him  the  sponge  tent. 

tion  of  the  tent  for  forty-eight  hours,  in  the  meantime  applying  pure  car- 
bolic acid  to  the  endometrium.  Before  using  the  sponge  tent  it  is  advis- 
able to  remove  most  of  the  grease  covering  it. 

Sponge  tents  may  be  passed  in  various  ways. 

(1.)  The  patient  is  placed  in  the  genu-facial,  or  better,  in  the  semiprone 
posture.  Sims'  speculum  is  passed,  the  anterior  lip  of  the  cervix  laid  hold 
of  with  a  volsella  and  drawn  down.  The  sponge  or  tangle  tent,  held  in 
forceps,  can  then  be  passed  into  the  cervix  (Fig.  102). 

(2.)  The  tent  is  fixed  on  the  spike  of  an  appropriate  instrument  and 
is  then  passed  just  as  the  uterine  sound  ;  i.e.,  with  the  patient  placed  in 
the  left  lateral  position,  the  index  and  middle  fingers  carried  into  the 


136 


MANUAL    OF    GYNECOLOGY. 


vagina  and  placed  on  the  anterior  lip  of  the  cervix.  The  tent,  fixed  on 
the  spike,  is  passed  along  these  fingers  and  its  point  made  to  enter  the 
cervix.  The  handle  is  then  rotated  and  carried  to  the  perineum. 

(3. )  The  patient  is  placed  on  her  left  side  and  athwart  the  bed.  Pass 
the  volsella,  draw  the  anterior  lip  of  the  cervix  down.  The  volsella  is  not 
always  needed.  Place  the  tent  between  the  index  and  middle  fingers  of 
the  left  hand  with  the  thumb  at  its  base,  carry  these  fingers  into  the  vagina 


Fig.  102. 

Sims'  diagram  illustrating  passage  of  tangle  tent.     Patient  is  semiprone,    Sims'  epeculum   passed,  and 
cervix  steadied  with  tenaculum.     The  tent  is  passed  with  forceps. 

with  their  dorsum  on  the  posterior  vaginal  wall,  make  the  point  of  the 
tent  enter  the  cervix  and  push  it  on  with  the  thumb. 

Another  way  is  to  use  the  volsella  as  above  described,  but  to  fasten  it 
to  the  bed.  Then  pass  Sims'  speculum,  holding  it  with  the  left  hand,  so 
that  the  tent  held  in  the  right  hand  can  be  passed  into  the  cervix  just  as 
one  would  thread  a  darning  needle. 

Tangle  and  Tupelo  Tents. — The  same  instructions  as  for  sponge  tents 
hold  good.  Tangle  tents,  however,  when  iised  to  correct  flexions  must 
first  be  moulded  as  follows :  Ascertain  the  curve  of  the  uterus  by 
bimanual  and  sound,  select  a  suitable  tent  and  dip  it  for  a  few  seconds 
in  boiling  water,  then  mould  it  to  uterine  curve  and  pass  it  as  already 
explained. 

Tents  require  to  be  left  in  the  cervix  for  a  period  varying  from  12  to  15 
hours,  and  the  vagina  should  be  frequently  douched  with  carbolic  lotion 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS. 


137 


during  this  time.  At  the  end  of  this  period  the  tent  requires  to  be  re- 
moved. During  the  removal  no  great  force  should  be  used.  Sometimes 
the  removal  is  difficult,  owing  to  constriction  by  the  os  internum  or  ir- 
re<mlarities  in  the  mucous  membrane. 

D 

The  cervix  is  generally  now  sufficiently  dilated  to  admit  of  digital 
examination  of  the  endometrium.  If  not,  another  tent  should  be  em- 
ployed. 

4.  Dangers  of  Sponge  and  Tangle  Tents  and  Contra-indications. — The 
practitioner  must  keep  prominently  before  him  that  the  use  of  a  tent  may 
prove  by  no  means  a  harmless  measure.  Cases  of  death  from  septicaemia 
after  the  careful  and  proper  use  of  one  tent  have  occurred.  The  patient 
runs  a  risk  proportionate  to  the  number  used ;  and,  therefore,  it  is  not 
advisable  to  use  more  than  two  consecutively  unless  under  special  circum- 
stances. They  are  not  to  be  used  if  acute  or  subacute  pelvic  inflamma- 
tion, ovaritis  (acute  or  chronic),  carcinoma  cervicis,  or  pelvic  hseruatocele 
be  present. 

The  reason  why  sponge  tents  may  prove  dangerous  is  only  too  ap- 
parent. The  uterine  mucous  membrane  is  a  lymphatic  surface  absorbing 


Fig.  103. 

Tait's  dilators. 

most  rapidly.  We  cannot  insert  sponge  tents  with  Listerian  precautions  ; 
and  in  addition  we  have  the  expanding  pressure  of  the  tent  forcing  septic 
matter  into  the  mucous  membrane.  Thus  it  is  quite  evident  that  the  con- 
secutive use  of  two  or  more  sponge  tents  is  dangerous. 

To  sum  up  briefly,  tents  are  highly  useful  in  necessary  cases — no  means 
at  the  disposal  of  the  gynecologist  gives  him  in  proper  cases  such  valuable 
help  ;  but  he  should  not  forget  the  risks  occasionally  arising  from  their  use 
— risks  which  should  make  him  cautious  but  not  timid. 


DILATATION  BY  GRADUATED  HARD  RUBBER  DILATORS — TAIT  S,  HANK  S. 

Tait's  dilators  consist  of  gi-aduated  vulcanite  cones  (Fig.  103)  which 
can  be  screwed  into  a  suitable  handle.     The  proximal  end  of  the  handle  is 


138 


MANUAL    OF    GYNECOLOGY. 


perforated  for  elastic  bands  which,  passing  in  front  and  behind,  are 
attached  to  a  suitable  belt  around  the  patient's  waist.  Thus  the  elasticity 
of  the  India-rubber  causes  the  cone  gradually  to  pass  up  into  the  cervix, 
dilating  it  as  it  goes.  By  this  apparatus,  Tait  claims  to  avoid  septic  in- 
fection and  to  dilate  rapidly. 

The  obvious  objection  to  this  apparatus  is  the  amount  of  watching  it 
entails  and  the  absence  of  the  pelvic  curve  on  the  handle. 

In  cases,  chiefly  of  abortion,  where  the  os  is  dilatable,  Hank's  dilators 


Fig.  104. 
Hank's  dilator.  (»/i) 


seem  serviceable.  They  have  the  oval  shape  seen  at  Fig.  104,  are  gradu- 
ated in  size  and  screw  into  the  sigmoid  handle.  They  can  be  used  man- 
ually to  dilate  the  cervix  until  the  fingers  can  be  passed  through. 


CHAPTER   XIII 
THE   CURETTE. 

LITERATURE. 

Mumti — The  Dull  Wire  Curette  in  Gynecological  Practice:  Ed.  Med.  Jour.,  XXIII., 
p.  819.  Xocjrjeratlt — Am.  J.  of  Obst. ,  IV.,  p.  o.  Recamicr — Memoire  sur  les  Pro- 
ductions Fibreuses  «.-t  les  Kongo-sites  Intrauteriues  :  Univ.  Med.,  18.">0.  ,^ims,  J. 
Murioh — Clinical  Notes  on  Uterine  Surgery:  London.  Simon — Die  Ausloffelung 
brcitbasiger  weicher  sarkomatoser  uud  carcinoinatoser  Geschwiilste  aus  Kiirper- 
hohleu  :  Beitriige  zur  Geburtshiilfe  YOU  der  Gesellschaft  iu  Berlin,  1872.  TIt'»n<ts 
— Op.  cit. 

THE  curette  is  an  instrument,  provided  with  a  cutting  or  with  a  dull  edge. 
\vliich  can  be  introduced  into  the  uterine  cavity  previously  dilated  In- 
tents (although  this  is  not  always  necessary)  for  the  purpose  of  scraping 
off  or  removing  abnormal  endometric  granulations,  sarcoma  of  the  mucous 
membrane,  carcinoma  of  the  cervix,  or  the  remains  of  an  incomplete  abor- 
tion. This  instrument  has  had  a  somewhat  chequered  career.  Origiinlly 
introduced  by  Kecamier,  whose  instrument  was  stiff  and  sharp,  it  did  good 
work  in  some  cases,  but  fell  into  disrepute,  undoubtedly  deserved,  after 
the  record  of  certain  instances  where  its  use  had  caused  perforation  <>f  the 
uterus.  Marion  Sims  and  Simon  recommend  a  modified  instrument  which, 
owing  to  its  stiff  unyielding  nature,  has  found  little  favour  with  the  pro- 


Loop  of  Rernmier's  rurrttc. 

fession.  Thomas  then  introduced  his  ilexible  dull  wire  curette,  which, 
popularised  by  Munde  in  an  able  article,  has  taken  its  place  in  the  gynecol- 
ogist's armamentarium  as  a  useful  instrument,  to  whose  employment  there 
is  attached  no  more  risk  than  attends  most  intrauterine  manipulations. 


140 


MANUAL    OF    GYNECOLOGY. 


There  are  four  varieties  of  curette— (1.)  Eecamier's  (Fig.  105);  (2.) 
Simon's  (Fig.  106) ;  (3.)  Thomas'  (Fig.  107) ;  (4.)  Sims'  (Fig.  108). 

Thomas'  instrument  is  9  inches  long,  and  has  a  handle  3£  inches  long. 
The  metal  portion  (5£"  long)  is  made  of  soft  copper  wire,  £  inch  thick 
near  the  handle,  and  ^  inch  thick  half  an  inch  from  the  end,  where  it 
forms  a  loop  (Fig.  107)  flattened  on  the  scraping  edge.  Russell  Simpson, 


Fig.  106. 

Simon's  spoon.  (%) 


Fig-  107. 
Thomas'  dull  wire  curette,  with  knob  added  by  Russell  Simpson. 


fff.  108. 
Sims'  curette,  with  flexible  shank :  a  and  ft,  extent  of  flexibility. 

of  Edinburgh,  has  modified  it  usefully  by  adding  a  knob  2£  inches  from 
the  point.  This  enables  one  to  use  it  with  more  precision. 

Cases  in  which  the  Curette  is  useful. — Recamier's  is  useful  in  the  same 
class  of  cases  as  Thomas'.  Simon's  is  specially  good  in  carcinomatous 
cervix,  but  not  in  endometric  conditions.  Thomas'  is  good  in  hyper- 
plastic  endometritis,  sarcoma  of  the  mucous  membrane,  and,  above  all, 
in  incomplete  abortion. 

It  is  evident,  from  what  has  been  said,  that  the  curette  aids  immensely 
in  intra -uterine  diagnosis.  By  it  portions  of  abnormal  intra-uterine  condi- 
tions can  be  removed  and  submitted  to  microscopic  investigation. 

How  to  use  Thomas'  Curette. — Place  the  patient  semiprone,  pass  Sims' 
speculum  and  draw  down  cervix  slightly  with  volsella.  Then  pass  in  the 
curette,  curved  if  needed  (no  previous  dilatation  with  tent  being  re- 
quired), and  gently  pass  it  over  the  mucous  membrane,  pressing  against 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS.     141 

it  while  the  loop  is  being  brought  down.  Do  this  systematically  over 
the  whole  anterior  and  posterior  uterine  surface,  remembering  its  shape 
(Fig.  14,  A). 

Curetting  may  be  done  single-handed  when  the  volsella  and  Battey's 
speculum  are  used,  as  described  at  p.  117  ;  or  in  some  cases  Fergusson's 
speculum  may  be  employed,  and  the  cervix  then  drawn  well  down  with 
the  volsella. 

After  the  curetting  is  finished,  apply  pure  carbolic  acid  to  the  endo- 
metrium  as  given  under  endometritis. 

Cautions  and  Dangers. — The  same  precautions  should  be  used  as  given 
under  sponge  tents.  The  dangers  have  proved  in  the  authors'  hands 
slight,  a  minor  attack  of  pelvic  peritonitis  being  the  worst. 


CHAPTER  XIY. 

KNIVES;  SCISSORS;  NEEDLES;  SUTURES;  ANTISEPTICS;  DOUCHES 
AND  SPRINGES;  CAUTERY;  ANAESTHETICS. 


KNIVES. 


FOE  perineal  operation,  the  surgeon's  ordinary  straight  bistoury  is  suffi- 
cient. For  vaginal  and  cervical  surgery,  long-handled  knives  with  the 
blade  straight  or  at  an  angle  to  the  shaft  are  required  (v.  under  operation 
for  vesico- vaginal  fistula). 


SCISSORS. 


These  are  of  the  greatest  use  to  the  gynecologist  and  supersede  the 
use  of  the  knife  in  many  instances.  Straight,  sharp-pointed  scissors  are 
valuable  in  repair  of  the  perineum.  Curved  scissors  are  necessary  for 
fistula  cases  (Fig.  109),  Bozeman's  being  specially  good.  They  are  right 


Pig-.  109. 
Simple  curved  scissors. 

and  left,  but  no  woodcut  gives  a  proper  idea  of  their  curves.  For  cer- 
vical operations,  stout  and  sharp  scissors  are  necessary.  It  is  very  im- 
portant to  remember  that  the  vaginal  portion  of  the  cervix  is  exceedingly 
tough,  and  that  the  ordinary  scissors  in  dividing  it  slip  down  or  even 
turn  obliquely,  leaving  the  tissue  uncut.  Kuchenmeister's  scissors  have 
this  tendency  obviated  by  one  of  the  blades  being  hooked  (Fig.  110). 
Even  these  scissors  sometimes  prove  unsatisfactory,  as  the  finger-and- 
thumb  grip  they  give  is  not  powerful  enough.  Fig.  Ill  shows  a  pair  of 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS. 


143 


cervical  scissors  devised  by  Hart,  where  the  handles  are  like  those  of  bone 
forceps  and  are  provided  with  a  ratchet.  They  can,  therefore,  be  grasped 
in  the  palm  of  the  hand  while  being  used,  and  cut  even  the  densest  cervix 


Fig.  110. 
Kuchenmeister's  scissors. 


Fig.  111. 
Hart's  cervical  scissors. 


with  great  precision.     Scissors  are  highly  useful  in  perineal,  vaginal,  and 
cervical  operations. 


NEEDLES. 


We  need  only  note  that  for  cervical  and  fistula  operations  strong  and 
short   needles  with  only  a  very  slight  curve  (or  perfectly  straight)  are 


144 


MANUAL    OF    GYNECOLOQY. 


needed.     The  cervical  tissue  is   so   dense  that  markedly  curved   slight 
needles  snap.     They  are  passed  with  a  needle  holder,  of  which  Fig.  113 


Fig.  112. 
Forms  of  needles  (Emmet). 


Fig.  113. 
Needle-holder. 

shows  a  simple  form.     Curved  or  tubular  needles  set  on  handles  are  also 
useful. 

SUTURES. 

These  may  be  silver  wire,  carbolized  silk,  catgut,  silk-worm  gut  or 
horse-hair.  For  fistulas,  deep  stitches,  and  cervical  laceration,  silver  wire 
is  best.  For  perineal  operations,  for  superficial  stitching,  as  also  for 
stitching  the  ovariotomy  incision,  silk-worm  gut  is  good.  Catgut  is 
valuable  in  the  rectal  stitches  of  complete  rupture  of  the  sphincter  ani. 
Carbolized  silk  (thin  and  fine)  is  best  for  the  ovariotomy  pedicle.  Simon 
also  used  silk  in  his  fistulas  cases.  Horse-hair  is  useful  for  superficial 
skin  stitches. 

ANTISEPTICS. 

This  naturally  divides  itself  into  two  sections :  viz.,  Listerism,  as  con- 
ducted in  peritoneal  operations  ;  and  the  modified  form  of  antiseptics 
carried  out  in  vaginal  and  cervical  surgery.  Details  on  the  first  of  these 
will  be  given  most  conveniently  in  speaking  of  ovariotomy.  We  may 
remark,  however,  that  at  present  the  question  of  the  propriety  of  the 
spray  in  peritoneal  operations  is  still  under  discussion.  Listerism  is 
directed  against  the  atmospheric  surrounding  of  wounds,  and  it  is  not  in 
any  sense  a  direct  treatment  of  wounds.  In  peritoneal  operations  there 
is  the  peculiarity  that  the  peritoneum  is  an  absorbing  sac  which  readily 
takes  up  carbolic  acid  in  the  form  of  the  finely  divided  spray.  Many 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS.  145 

eminent  ovariotomists  allege,  therefore,  that  the  spray  at  present  considered 
necessary  for  Listerism  is  hurtful  in  all  peritoneal  operations  ;  and  that 
it  causes,  for  the  reason  already  given,  high  temperatures  and  kidney  com- 
plications. This  has  not  been  absolutely  proved,  but  is  worthy  of  the 
careful  attention  of  all  operators.  Even  if  sustained,  it  does  not  invali- 
date the  high  claims  of  Listerism  on  general  surgery. 

During  perinea!,  vaginal,  and  cervical  operations  the  use  of  the  douche 
is  invaluable.  For  this  purpose  a  large  douche  apparatus  filled  with 
carbolic  lotion,  1-40,  with  long  indiarubber  tube  and  small  narrow  nozzle 
is  employed.  It  is  placed  somewhat  above  the  level  of  the  part  to  be 
operated  on,  and  under  the  charge  of  an  assistant  plays  a  small  jet  on  the 
surface.  Apart  from  its  valuable  antiseptic  action,  it  clears  away  blood 
from  the  cut  surfaces,  enables  the  operator  to  pare  the  fistular  edges  very 
exactly,  and  altogether  is  a  most  valuable  help.  It  can  be  suitably 
warmed ;  and  the  excess  of  fluid  flows  into  any  receptacle,  such  as  a  foot- 
bath or  large  tray  on  which  the  legs  of  the  table  are  placed.  Instead  of 
carbolic  lotion,  boracic  or  thymol  lotion  can  be  substituted. 

VAGINAL  SYRINGES  AND  DOUCHES. 

For  the  purpose  of  applying  antiseptic  and  astringent  lotions  to  the 
vagina  and  split  cervix,  for  hot-water  injections,  and  for  merely  cleansing 
purposes,  the  vaginal  syringe  and  douche  are  employed. 

Vaginal  Syringes. — Fig.  114  shows  the  well-known  Higginson  syringe. 


Fig.  114. 

Higginaon's  syringe. 

Valuable  as  this  is,  it  is  difficult  for  ordinary  patients  to  manage  single- 
handed.     For  them  we  should  therefore  recommend  the 

Vaginal  Douche. — A  convenient  form  of  this  is  shown  at  Fig.  115.  It 
can  be  hung  up  after  being  filled,  and  by  the  gravitation  thus  afforded  a 
gentle  flow  is  obtained.  The  overflow  from  the  vagina  is  received  into 
any  suitable  receptacle  on  which  the  patient  sits. 


146 


MANUAL    OF    GYNECOLOGY. 


For  patients  in  bed  its  use  is  equally  easy.  The  nurse  or  attendant 
should  be  instructed  to  make  the  patient  lie  on  her  back,  the  hips  being 
well  raised  with  a  pillow.  The  pillow  itself  should  be  covered  with  a 


Fig.  115. 
Vaginal  douche. 

waterproof  or  folded  blanket.  An  ordinary  basin  is  then  slipped  below 
the  hips  to  receive  the  overflow. 

According  to  some,  the  force  of  the  jet  of  water  given  by  the  Higgin- 
son  is  specially  valuable — why  is  not  very  evident. 

The  great  advantage  of  the  douche  is  its  simplicity.  Half  of  the  women 
who  buy  a  Higginson  do  not  know  how  to  use  it,  and  find  it  troublesome 
even  when  they  do  know. 

The  material  for  injection  is  varied.  Hot  water,  as  hot  as  the  patient 
can  bear  it,  is  invaluable  in  inflammatory  conditions. 

Hot  carbolic  lotion  (equal  parts  of  boiling  water  and  1-20  lotion)  is 
admirable  in  abortion  cases,  for  cleansing  purposes. 

In  leucorrhceal  conditions  ;  injections  of  alum  (  3  j-  to  Oj.),  sulphate  of 
copper  (  3  ss.  to  Oj.),  sulphate  of  zinc  (  3  ss.  to  Oj.)  are  good. 

The  general  formula  for  these  is — 

]J.  Aluminis,  vel 

Cupri  Sulphatis,  vel 

Zinci  Sulphatis 3  j> 

Fiat  pulv  ;  mitte  tales  xij. 
Sig.  To  be  used  as  directed. 


EXAMINATION    OF    THE    FEMALE    PELVIC    ORGANS. 


14! 


The  patient  is  told  to  dissolve  one  powder,  or  half  of  one,  in  a  pint  of 
water,  to  place  this  in  the  douche  and  use  it  as  already  explained. 

It  is  a  good  plan  to  make  the  patient  first  douche  with  hot  water  and 
then  finally,  in  the  dorsal  posture,  to  finish  up  with  the  special  lotion. 
After  it  is  finished  the  dorsal  posture  should  be  maintained  for  ten  min- 
utes, and  the  last  of  the  injection  expelled  by  sitting  up. 


CAUTEEY. 


The  ordinary  cautery  may  be  employed  in  the  treatment  of  the  pedicle 
in  ovariotomy.  Details  on  this  are  postponed  till  that  is  considered. 

Fig.  116  shows  the  well-known  Paquelin's  cautery.  In  this  very  elegant 
and  useful  instrument  the  vapour  of  benzoline  is  pumped  through  a  slender, 


Fig.  116. 

Paquelin's  cautery  and  Wilson's  antithermic  shield.    The  shield  is  seen  covering  the  rod.    The  water 
apparatus  is  to  the  right.     A  spirit-lamp  is  also  figured  (Muud6). 

hollow  cone  of  platinum,  the  latter  being  previously  heated  in  a  gas  flame 
or  spirit  lamp.  It  speedily  becomes  red  or  white  hot  by  the  combustion 
of  the  vapour,  and  can  then  be  used. 

Note  as  to  its  use — (1)  To  be  careful  with  the  benzoline,  as  it  is  exceed- 
ingly inflammable  ;  (2)  To  heat  the  platinum  cone  first  (in  outermost  zone 
of  the  flame)  before  pumping  in  the  benzoline.  If  the  vapour  is  pumped 
in  before  the  platinum  is  hot  enough  to  ignite  it,  the  cone  is  cooled  by  its 
cold  stream.  i 

The  cautery  should  be  used  at  a  dull  heat.  When  white  hot  it  causes 
bleeding,  because  it  thoroughly  burns  the  tissues  and  thus  leaves  no  char 
to  act  as  a  haemostatic. 


148 


MANUAL    OF    GYNECOLOGY. 


When  used  to  cauterize  the  cervix,  care  should  be  taken  that  the  hot 
metal  rod  does  not  touch  the  vaginal  walls.  It  requires  considerable  care 
to  avoid  this.  Various  plans  have  been  tried.  Thus  the  rod  may  be  cov- 
ered except  at  its  terminal  two  inches  with  a  wooden  case  which  must  not 
touch  the  metal  More  recently  Dr.  Wilson  of  Baltimore  has  devised  an 


Eg.  117. 

Various  forms  of  Paquelin's  canes,  A,  rectangular ;  B,  curved  ;  C,  straight. 

antithermic  shield  through  which  a  stream  of  cold  water  is  sent  by  an  ap- 
propriate apparatus  (Fig.  116).  Fig.  117  shows  some  of  the  various  rods 
of  Paquelin's  cautery  ;  and  Fig.  116  the  same  covered  with  Wilson's  anti- 
thermic shield. 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS.  149 

ANESTHETICS. 

LITERATURE. — Brunton,  T.  L. — Remarks  on  One  of  the  Causes  of  Death  during  the 
Extraction  of  Teeth  under  Chloroform,  Br.  Med.  J.,  II.,  1875,  p.  395.  Chiene — 
Chloroform,  London  Practitioner,  January,  1877.  Hart,  D.  B. — On  Death  from 
Insufficient  Administration  of  Chloroform,  Ed.  Med.  J.,  1879.  Lister — Chloroform 
in  Holmes'  System  of  Surgery,  Vol.  V.  :  Report  of  Br.  Med.  Aeso.  Committee,  Br. 
Med.  J.,  Vol.  I.,  1879. 

The  chief  anaesthetics  are  chloroform  and  ether.  Other  agents  or  mix- 
tures have  been  tried,  viz.,  ethidene  ;  mixtures  of  alcohol,  ether,  and  chloro- 
form ;  nitrous  oxide  ;  bichloride  of  methylene  :  the  results  have  not  been 
satisfactory  with  these.  In  the  British  Medical  Report  on  the  action  of 
anaesthetics,  ethidene  is  strongly  recommended.  Chloroform  and  ether, 
however,  still  remain  our  most  trustworthy  agents. 

Action  of  Chloroform. — Chloroform  when  administered  to  a  patient  has 
a  perfectly  definite  effect  on  the  nervous  system.  Sensation  is  first  abol- 
ished, and  then  reflex  action.  This  is  all  the  effect  wished  for  in  any  case. 
If,  however,  the  chloroform  be  pushed  farther,  the  respiratory  centre  be- 
comes paralyzed,  so  that  breathing  ceases,  and  finally  the  heart  stops  from 
paralysis  of  its  ganglia.  In  almost  all  cases  this  is  the  sequence  in  the  sus- 
ceptibility to  chloroform  of  those  parts  of  the  nervous  system  regulating 
sensation,  reflex  action,  respiration,  and  the  circulation.  Rarely  have  we 
the  heart  affected  before  the  respiratory  centre.  When  first  administered 
it  causes  a  transient  rise  in  the  blood- pressure,  and  then  a  gradual  irregu- 
lar fall  The  nfore  recent  investigators  on  this  point  (see  the  British 
Medical  Report)  found  that  in  dogs  chloroform  reduced  the  blood-press- 
ure more  rapidly  and  to  a  greater  extent  than  ethidene,  and  that  ether  did 
not  cause  any  appreciable  depression.  As  the  blood-pressure  is  the  re- 
sultant of  the  force  and  frequency  of  the  heart's  action  and  the  state  of 
dilatation  of  the  small  blood-vessels,  it  is  evident  that  chloroform  when 
administered  to  dogs  slowed  the  heart  and  weakened  the  vasomotor  centre 
more  than  ethidene  or  ether.  It  should  be  kept  in  mind,  however,  that 
dogs  are  very  susceptible  to  the  action  of  chloroform  and  easily  killed 
by  it. 

It  is  wrong  to  suppose  that  in  every  chloroform  death  the  fatal  result 
is  caused  by  an  overdose  of  chloroform,  or  by  the  action  of  the  chloroform 
on  a  fatty  heart.  This  is  a  very  common  view,  but  an  exceedingly  erron- 
eous one. 


150  MANUAL    OF    GYNECOLOGY. 

The  one  great  object  of  ansethesia  is  to  prevent  the  patient's  feeling 
pain.  This  is  one  of  its  most  gratifying  results,  but  it  is  not  by  any  means 
the  great  object  in  operative  cases.  One  of  the  most  essential  aims  of  its 
'administration  is  to  prevent  the  reflex  transmission  of  powerful  nervous 
impulses  from  the  part  operated  on  to  the  heart,  or  their  direct  transmis- 
sion to  the  respiratory  or  vasomotor  centres.  If  chloroform  be  admin- 
istered to  a  limited  extent  so  that  sensation  alone  is  abolished,  and  if  any 
large  nervous  trunk  like  the  Fifth,  or  large  nervous  area  like  the  Splanch- 
nic, be  irritated,  then  we  may  have  reflex  inhibition  of  the  heart,  or 
paralysis  of  the  vasomotor  and  respiratory  centres  ;  in  man,  death  may 
result.  There  are  good  clinical  reports  that  this  1'eflex  inhibition  of  the 
heart  has  caused  its  stoppage  in  man.  It  is  sometimes  urged  against  this 
that  no  amount  of  stimulation  of  the  lower  end  of  the  cut  vagus  in  a  rab- 
bit can  permanently  stop  its  heart ;  in  man,  however,  the  conditions  are 
not  the  same  as  in  the  rabbit.  Goltz,  quoted  by  Lauder  Brunton,  gives 
some  most  interesting  facts  in  this  connection.  A  frog  was  decapitated, 
its  heart  exposed,  and  the  animal  hung  with  its  legs  downwards.  On  tap- 
ping the  intestines  pretty  hard,  the  heart  stopped  through  reflex  inhibition 
of  the  vagus  but  soon  resumed  again.  It  contracted  vigorously  but  had 
no  blood  in  it  to  propel.  The  irritation  of  the  splanchnics  had  not  only 
inhibited  the  heart  but  so  lowered  the  tone  of  the  vasomotor  centre  that 
the  veins  of  the  abdominal  cavity  were  widely  dilated ;  and  thus  the  blood, 
when  the  animal  was  vertical,  did  not  reach  the  opening  of  the  inferior  vena 
cava  into  the  right  auricle.  When  the  frog  was  laid  on  its  back,  however, 
the  blood  flowed  at  once  to  the  heart. 

This  then  gives  us  the  proper  view  of  the  administration  of  chloroform 
in  all  cases  where  cutting  operations  or  operations  involving  large  nervous 
trunks  are  being  performed. 

The  chloroform  must  be  pushed  until  sensation  and  reflex  action  are  abol- 
ished, and  this  state  is  to  be  kept  up  during  the  operation. 

Uses. — Chloroform  is  used  in  all  cutting  operations  except  in  very 
slight  ones;  in  cases  where  the  straining  of  the  patient  prevents  the 
manipulation  necessary  for  accurate  diagnosis  and  treatment ;  in  cases  of 
phantom  tumors ;  and  also,  when  necessary,  in  cases  where  vaginal  exami- 
nation of  virgins  is  requisite. 

In  division  of  the  cervix,  curetting  of  the  endometrium,  and  applica- 
tion of  caustics  to  the  endometrium,  it  is  unnecessary  unless  the  patient 
is  unusually  sensitive. 


EXAMINATION    OF   THE    FEMALE    PELVIC    ORGANS. 


151 


Method  of  Administration. — The  patient  should  have  no  food  for  three 
or  four  hours  prior  to  the  operation.  Just  before  the  administration  of 
chloroform  is  begun,  half  a  glass  of  wine  or  brandy  may  be  given. 

The  patient  should  lie  on  her  back  with  all  fastenings  unloosed,  and 
should  not  sit  up.  A  towel  or  napkin  folded  square  is  taken  and  chloro- 
form poured  on  it.  Fig.  118  shows  a  convenient  and  economic  drop 
cork  which  can  be  fitted  into  any  bottle.  The  amount  does  not  matter. 
We  judge  of  the  state  of  the  patient  not  by  the  amount  poured  on  the 
cloth  but  by  the  effect  on  the  patient.  If  reflex  action  be  not  abolished, 


Fig.  118. 
Chloroform  drop  cork. 

even  though  a  quart  has  been  used,  the  patient  has  not  had  enough ; 
while,  if  respiration  be  affected  after  a  few  whiffs,  she  has  had  too  much. 

The  face  of  the  patient  should  look  to  the  side  and  the  chin  should  be 
kept  well  away  from  the  sternum.  The  administrator  should  keep  the 
chin  forward  with  his  right  hand.  This  is,  in  addition,  valuable,  as  he 
can  always  feel  the  puff  of  the  breath  on  the  palm. 

The  cloth  is  to  be  held  not  too  closely  over  the  face,  and  the  patient 
directed  to  take  long  breaths. 


152  MANUAL    OF    GYNECOLOGY. 

The  administrator  has  to  keep  two  points  before  him.  He  is  to 
watch  the  breathing  most  narrowly,  and  to  a  scertain  when  reflex  action 
is  abolished. 

He  can  watch  the  breathing  well  by  feeling  the  puff  of  the  breath 
constantly  on  his  hand.  The  abolition  of  reflex  action  is  generally  tested 
by  touching  the  conjunctiva ;  when  the  patient  is  not  fully  under,  the 
orbicularis  contracts.  This  is  not  a  perfect  test,  but  the  best  we  have. 

When  reflex  action  is  abolished,  no  more  chloroform  is  to  be  given ; 
should  it  show  signs  of  returning,  fresh  chloroform  is  put  on  the  cloth. 


DANGERS.  ! 

These  may  be  the  following  : — 
(1.)  Asphyxia, 
(2. )  Reflex  inhibition  of  Heart  or  Respiratory  or  Vasomotor  Centres. 

(1.)  Asphyxia. — This  may  arise  early  from  fainting,  muscular  relaxa- 
tion allowing  the  tongue  to  fall  back  on  the  pharynx  ;  or  from  closure  of 
the  glottis,  owing  to  paralysis  of  its  intrinsic  muscles.  The  marked  ex- 
tension of  the  head  already  insisted  on,  prevents  the  former  from  happen- 
ing. If  it  arise,  the  tongue  is  to  be  pulled  well  forward  with  a  pair  of 
forceps.  Foulis  recommends  that  the  tongue  be  pressed  forward  by  a 
spatula  or  spoon  applied  at  its  root. 

When  asphyxia  arises  from  paralysis  of  the  respiratory  centre,  owing 
to  an  overdose  of  chloroform,  the  treatment  is  immediate  stoppage  of  the 
administration  of  the  chloroform  and  artificial  respiration  by  Sylvester's  or 
Howard's  method  for  hours  if  necessary.  The  head  should  be  kept  hanging- 
over  the  edge  of  the  table,  so  as  to  send  blood  to  the  respiratory  centre  ; 
or  the  patient  may  be  inverted  (Nelatonized). 

(2.)  Reflex  inhibition  of  the  Heart  or  Respiratory  or  Vasomotor  Centres. — 
This  can  only  happen  when  there  has  not  been  given  sufficient  chloroform 
to  abolish  reflex  action.  It  is  by  no  means  an  uncommon  thing,  therefore, 
for  the  patient  to  die  because  sufficient  chloroform  has  not  been  ad- 
ministered ;  sensation  alone  has  been  abolished  when  the  operation  is 
begun.  The  usual  account  is  that  "  the  patient  gave  a  start  when  the 
first  incision  was  made,  and  died."  In  some  cases  this  has  happened  after 
only  a  teaspoonful  had  been  poured  on  the  cloth.  Yet  this  is  often  called 
"a  death  from  chloroform." 

Contra-indications. — Every  patient  on  whom  an  operation  is  to  be  per- 


EXAMINATION     OF    THE    FEMALE    PELVIC    OliGAXS.  153 

formed  may  have  chloroform  ;  if  the  operation  is  indicated,  so  is  chloro- 
form. If  the  patient  has  a  weak  heart,  then  chloroform  is  imperative 
for  airy  operation  ;  it  must  be  given  till  rellex  action  is  abolished,  as  any 
reflex  inhibition  of  the  heart  is  specially  dangerous  here. 

Occasionally,  chloroform  causes  severe  vomiting  after  the  operation. 
For  this  reason  Keith  always  uses  ether  instead.  Vomiting  during  the 
operation  is  dangerous  only  when  any  solid  vomit  regurgitates  back  into 
the  trachea  ;  tracheotomy  may  then  be  necessary. 

Sickness  after  the  operation  is  treated  by  the  sucking  of  ice  and  the 
application  of  a  mustard  leaf  to  the  pit  of  the  stomach. 


PART  II. 

DISEASES  OF  THE  FEMALE  PELVIC  ORGAN'S. 

"NVi:  classify  the  diseases  of  the  female  pelvic  organs  according  to  the 
structure  which  is  affected,  and  devote  oiie  section  to  each  group  of  affec- 
tions as  follows  : 

Section  HI.  The  Peritoneum  and  Connective  Tissue  ; 
IV.  The  Fallopian  Tubes  and  Ovaries  ; 
V.   The  Uterus  ; 
VI.   The  Vagina  ; 
VII.   The  Vulva  and  the  Pelvic  Floor. 

Further,  we  shall  consider  under  special  sections  disturbances  of  the 
following  functions  : 

•Section  VIII.   The  Menstrual  Function  ; 

IX.  The  Reproductive  Function. 

Finally,  we  shall  devote  one  section  to  affections  of  the  neighboring 
.  >rgans  : 

Section  X.  The  Bladder  and  the  Rectum. 

Syphilis  and  Chlorosis,  as  they  arc  constitutional  conditions,  will  be 
considered  in  the  Appendix,  in  which  also  a  chapter  will  be  given  to  Case- 
taking  and  to  Gynecological  Literature. 


SECTION  TIL 

AFFECTIONS    OF    PERITONEUM    AND    CONNEC- 
TIVE TISSUE. 

CHAPTER  XV.  Pelvic  Peritonitis  and  Pelvic  Cellulitis. 
"      XVI.  Pelvic  Hsematocele. 


CHAPTER  XV. 
PELVIC  PEBITONITIS  AND  PELVIC  CELLULITIS. 

LITERATURE. 

Bnndl— Op.  cit.  Barnes— Op.  cit.  Bernutz  and  Gouptt—  Clinical  Memoirs  of  the 
Diseases  of  Women,  Vol.  II.  :  New  Sydenham  Society,  Meadow's  translation,  18GO. 
Churchill — On  Inflammation  and  Abscess  of  the  Uterine  Appendages  :  Dub.  J.  of 
Med.  Sc. ,  1843.  Doherty — On  Chronic  Inflammation  of  the  Uterine  Appendages 
after  Childbirth  :  Dub.  J.  of  Med.  Sc.,  1843.  Duncan,  J".  Mathews — A  Practical 
Treatise  on  Perimetritis  and  Parametritis  :  Edinburgh,  A.  &  C.  Black,  18G9. 
Freund—Op.  cit.  Lvsk — Op.  cit.  Mund'',  P.  F. — The  Diagnosis  and  Treatment 
of  Obscure  Pelvic  Abscess  in  Women,  with  Remarks  on  the  Differential  Diagnosis 
between  Pelvic  Peritonitis  and  Pelvic  Cellulitis:  Archives  of  Medicine  (E.  C. 
Seguin,  Ed.),  Vol.  IV.,  No.  3.  MtcDonald,  Angus— Three  Cases  of  Parametritis, 
with  Observations  on  its  Diagnosis  and  Treatment :  Ed.  Med.  J.,  1880,  p.  10GO. 
Noeggerath — Latent  Gonorrhoea,  especially  with  regard  to  its  Influence  on  Fertility 
in  Women :  Am.  Gyn.  Tr.,  Vol.  I.  Olshausen — On  Puerperal  Parametritis  and 
Perimetritis:  New  Syd.  Soc.  Trangl.,  1876.  Priestky,  W.  0.—  Pelvic  Cellulitis 
and  Pelvic  Peritonitis :  Reynolds'  System  of  Medicine,  Vol.  V.  Schroeder — Op. 
cit.  Schultze,  B.  8. — Ueber  die  Pathologische  Anteflexion  der  Gebarmutter  und 
die  Parametritis  Posterior  :  Hirschwald,  Berlin,  1875.  DeSinety — Op.  cit.  Simp- 
son, Sir  J.  Y. — On  Pelvic  Cellulitis  and  Pelvic  Peritonitis,  Clinical  Lectures  on 
the  Diseases  of  Women  (edited  by  Simpson,  A.  Russell) :  Edinburgh,  A.  &  C. 
Black,  1872.  Simpson,  Russell— Quarterly  Report  of  the  Royal  Maternity  and 
Simpson  Memorial  Hospital :  Ed.  Med.  Journal,  Vol.  XXVI.,  p.  1059.  Spiegelberg 
— Remarks  upon  Exudations  in  the  Neighborhood  of  the  Female  Genital  Organs  : 
Second  Series  of  German  Clinical  Lectures,  Translated  by  New  Sydenham  Society, 
1877.  Tait,  Lawson — On  the  Treatment  of  Pelvic  Suppuration  by  Abdominal 
Section  and  Drainage  :  Tr.  of  Med.  Chi.  Soc.,  Lond.,  1880,  p.  307. 

IN  considering  the  subjects  of  pelvic  peritonitis  and  pelvic  cellulitis  it  will 
be  convenient  to  take  up  some  preliminary  matter  and  then  to  consider 
separately  each  condition  under  the  following  heads  : 

Nature. 

Pathological  anatomy  and  varieties. 

Etiology. 


160  MANUAL    OF    GYNECOLOGY. 

Symptoms. 

Physical  signs. 

Diagnosis  :  Differential  diagnosis. 

Course  and  results. 

Prognosis. 

Treatment. 

Preliminary  Considerations. — The  subjects  of  pelvic  peritonitis  and 
pelvic  cellulitis  are  by  no  means  thoroughly  worked  out.  The  literature 
is  extensive,  but  not  so  valuable  as  medical  literature  often  is.  This 
arises  from  various  causes,  among  which  the  most  important  is  the 
change-  in  the  theories  as  to  the  anatomical  site  of  pelvic  inflammatory 
conditions.  Nonat  and  Simpson  contended  that  pelvic  peritonitis  and 
pelvic  cellulitis  were  distinct  affections,  and  considered  the  latter  as 
being  of  frequent  occurrence.  Then  Bernutz  and  Goupil  turned  the  tide 
for  some  time  by  their  able  work,  where  they  classed  almost  all  pelvic 
inflammatory  affections  as  peritonitic.  They,  however,  greatly  under- 
rated the  amount  of  connective  tissue  surrounding  the  cervix,  just  as 
Guerin  has  more  recently  written  in  the  same  strain  as  to  the  connective 
tissue  of  the  broad  ligaments ;  and  Le  Bee,  too,  has  endeavored  to  sup- 
port the  opinions  of  the  latter  by  his  observations  on  the  lymphatic  distri- 
bution of  the  broad  ligament. 

There  is  now  little  doubt  that  Bernutz  and  Goupil  pushed  their  views  too 
far  ;  so  that  in  America,  Germany,  and  Britain,  gynecologists  now  consider 
pelvic  inflammation  as  either  peritonitic  or  cellulitic.  Clinical,  anatomical 
and  pathological  facts  are  each  day  putting  this  view  on  a  firmer  basis. 
The  fact,  however,  that  these  diseases  are  not  rapidly  fatal,  and  that  gen- 
erally we  get  post-mortems  only  of  advanced  or  resolved  cases,  along  with 
the  admitted  difficulty  of  exact  clinical  differentiation,  renders  our  know- 
ledge at  present  much  less  complete  and  exact  than  could  be  wished. 

Finally,  we  must  note  that  both  diseases  are  always  combined.  Thus 
in  a  marked  pelvic  peritonitis  there  is  always  some  pelvic  cellulitis,  and  in 
a  marked  pelvic  cellulitis  always  some  pelvic  peritonitis.  This  is  quite 
analogous  to  what  is  found  in  pleurisy  and  pneumonia. 

PELVIC  PERITONITIS. 

SYNONYMS. — Perimetritis  ;  Pelveo-peritonitis. 

NATURE. — An  acute  or  chronic  inflammatory  condition  affecting  chiefly 
the  pelvic  peritonei.Nm. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       1G1 
PATHOLOGICAL   ANATOMY    AND    VARIETIES. 

In  the  early  stages,  the  peritoneum  is  injected  and  the  epithelial  cells 
dull  in  lustre.  Soon,  in  marked  cases,  fibrinous  or  serous  fluid  is  poured 
out :  the  former  stiffens  the  peritoneum  and  often  causes  extensive  adhe- 
sions between  uterus  and  rectum,  Fallopian  tubes  and  ovary ;  the  latter 
either  remains  free  in  the  cavity,  or  becomes  encysted  by  the  false  mem- 
branes already  alluded  to,  often  making  Douglas'  pouch  to  bulge  down. 
In  bad  cases,  pus  is  the  secretion.  We  may  therefore  speak  of  simple 
pelvic  peritonitis,  adhesive  pelvic  peritonitis,  and  serous  or  purulent  pelvic 
peritonitis.  These,  however,  are  mere  varieties. 

ETIOLOGY. 

The  causes  of  pelvic  peritonitis  are  numerous.  They  are  chiefly  the 
following : — 

1.  The  previous  existence  of  a  pelvic  cellulitis  ;  pelvic  hsema- 

tocele  ;  ovaritis  ;  ovarian  tumor  ;  fibroid  tumor  ;  tubercle, 
and  carcinoma. 

2.  Childbirth  and  abortion. 

3.  Gonorrhoea. 

4  Latent  gonorrhoea  in  the  Male. 

5.  Menstruation. 

6.  Venereal  excess. 

7.  Instrumental  examination  by  the  sound  :   stem  pessaries ; 

sponge  tents  ;  tangle  tents. 

1.  The  previous  existence  of  a  pelvic  cellulitis  ,•  ovaritis:  ovarian  tumor ; 
fibroid  tumor  ;  tubercle,  and  carcinoma. 

We  have  already  noted  that  marked  pelvic  cellulitis  is  always  asso- 
ciated with  some  pelvic  peritonitis.  The  pelvic  peritoneum  and  cellular- 
tissue  are  adjacent  and  intimately  connected  with  one  another  in  their 
vascular,  nervous,  and  especially  in  their  lymphatic  supply.  We  have 
already  seen  how  the  stomata  of  the  peritoneum  communicate  with  sub- 
endothelial  lymphatics.  In  the  same  way  we  can  understand  a  pelvic 
peritonitis  arising  secondarily  from  ovaritis. 

Ovarian  tumors  often  set  up  pelvic  peritonitis  after  being  tapped,  as 
well  as  from  their  mere  mechanical  pressure — a  fact  of  the  highest  im- 
portance as  regards  the  operation  of  ovariotomy.  Small  fibroids,  tubercle 

and  cancer  do  the  same,  and  thus  give  rise  to  considerable  difficulty  in 
VOL.  I.-ll 


162  MANUAL    OF    GYNECOLOGY. 

diagnosis.  Dr.  Foulis,  of  Edinburgh,  has  thrown  much  light  on  malig- 
nant peritonitis,  by  showing  that  in  the  ascitic  fluid  we  find  very  character- 
istic cell  clusters.  This  will  again  be  referred  to  under  ovarian  tumor. 

2.  Childbirth  and  Abortion. — When  an   inflammatory   lesion    follows 
these,  it  is  generally  cellulitic  and,  as  we  shall  afterwards  see,  septic. 
Pelvic  peritonitis  often  enough  follows,  and  is  then  probably  likewise 
septic.     According  to  Lusk,  who  quotes   Steurer's  as  yet  unpublished 
researches,   "bacteria  pass  along  the  lymphatics  .     .     .  and  perforating 
those  beneath  the  peritoneum  set  up  pysemic  peritonitis."     At  the  same 
time,  the  peritonitis  may  result  from  simple  bruising. 

3.  GonorrhcRa  is  one  great  cause  of  peritonitis.     It  may  result  from 
actual  spread  of  the  gonorrhceal  virus  ;  or  be  sympathetic,  like  orchitis  in 
the  male.     In  the  former  case  the  purulent  infection  probably  passes 
along  the  Fallopian  tubes  and  out  at  the  fimbriated  end,  setting  up  a 
severe  peritonitis.     In  puerperal  women,  gonorrhoea  is  by  no  means  inno- 
cent therefore,  as  the  following  case  by  Russell  Simpson  shows : — 

"  J.  C.,  primipara,  prostitute,  set.  18,  admitted  to  the  hospital  and  was 
delivered  of  a  male  child.  On  the  afternoon  following  severe  peritonitis 
set  in,  which  proved  fatal  in  ten  days.  On  post-mortem  the  abdomen  con- 
tained §  viii.  of  yellow  pus.  Surface  of  intestines  covered  with  recent 
fibrinous  lymph  becoming  purulent.  Mucous  membrane  of  bladder  much 
congested  and  in  certain  areas  rough  and  granular.  .  .  .  On  squeezing 
the  Fallopian  tubes  a  large  quantity  of  pus  was  expelled  and  the  tubes  ap- 
peared to  be  much  distended  with  it.  Mucous  membrane  much  con- 
gested "  (Report  by  Dr.  D.  J.  Hamilton). 

4.  Latent  Gonorrhoea  in  the  Male. — By  this  term  Noeggerath  of  New 
York,  who  first  directed  attention  to  the  subject,  means  a  gonorrhoea  in  the 
male  apparently  cured,  which  some  time  after — even  two  years— infects  a 
virgin  vagina,  causing  discharge  and  pelvic  peritonitic  disturbance.     This 
subject  comes  up  under  Gonorrhoea.     The  authors  have  seen  some  cases 
bearing  out  Noeggerath's  views. 

5.  Menstruation. — It  can  be  readily  understood  how  the  pelvic  conges- 
tion of  menstruation  may  in  certain  cases  cause  peritonitis.     There  may 
be  some  blood  effused  which  sets  it  up. 

6.  Venereal  excess  in  prostitutes  and  newly  married  women  may,  for 
evident  reasons,  have  peritonitis  as  its  sequel. 

7.  Instrumental  Manipulation. — This  is  alluded  to  under  the  various  in- 
struments and  needs  mere  mention  here. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       163 

We  append  Bernutz's  analysis  of  the  causes  of  pelvic  peritonitis  in 
ninety-nine  cases. 

43  occurred  in  puerperse. 

28         "        after  gonorrhoea. 

20        "        during  menstruation. 

3  due  to  venereal  excess. 

2      "      syphilitic  diseases  of  cervix. 
8  traumatic  4  _  .  ,     ,     , .        , ,, 

2  introduction  of  the  uterine  sound. 

1      "      use  of  vaginal  douche. 


SYMPTOMS   AND   PHYSICAL   8I<3Na 

A.  Acute  Peritonitis. 

Symptoms. — Increased,  full,  and  bounding  pulse ;  increased  tempera- 
ture ;  rigor  ;  shooting  pains  very  severe. 

Physical  Signs. — On  palpation  of  lower  part  of  abdomen  the  patient 
complains  of  pain ;  and  the  abdominal  muscles,  apart  from  the  patient's 
volition,  resist  pressure.  She  lies  usually  on  her  back,  and  with  both  legs 
drawn  up. 

On  vaginal  examination  the  vagina  feels  hot  and  tender,  and  pulsating 
vessels  may  be  felt  in  the  fornices. 

After  exudation  is  present  we  may  feel  one  or  other  of  the  following 
conditions. 

1.  A  flat,  hard,  non-bulging  condition  of  the  fornices  round  the  cervix, 
which  is  not  displaced  to  one  or  other  side  but  is  immobile.     The  usual 
simile,  and  a  very  good  one,  is  that  it  feels  as  if  plaster-of-Paris  had  been 
poured  into  the  pelvis. 

2.  An  indistinct  fulness  high  up  in  the  pelvis.   This  is  from  free  serous 
exudation. 

3.  A  bulging  tumour  behind  the  uterus  displacing  it  to  the  front ;  or 
a  tense  fluid  laterally,  apparently  in  the  site  of  the  broad  ligament  (Fig. 
45).     The  former  is  due  to  encysted  serous  effusion  in  the  pouch  of  Doug- 
las, the  latter  to  encysted  serous  fluid  behind  the  broad  ligament  displa- 
cing it  forwards.     As  a  general  rule  these  effusions  are  high  in  the  pelvis 
and  symmetrical.      Sometimes   the   bulging   retro-uterine   tumour  feels 
nodulated  after  a  time  ;  this  is  from  extension  of  the  inflammatory  con- 
dition into  the  subjacent  connective  tissue. 

Note  that  the  bimanual  is  often  impossible  owing  to  the  rigid  condition 


164  MAtfUAL    OF    GYNECOLOGY. 

of  the  fornices  and  abdominal  muscles.  The  bimanual  estimation  of 
effusion  is  often  wrong,  owing  to  the  fact  that  we  feel  the  rigid  peritoneal 
.membrane  through  the  fornices,  and  from  the  rigidity  of  the  abdominal 
wall  draw  the  conclusion  that  there  is  effusion  between  these.  Careful 
examination  under  chloroform  is  of  the  highest  value  in  such  instances. 

B.  Chronic  Peritonitis. 

Symptoms. — These  are  chiefly  backache,  sideache,  leucorrhcea,  in- 
creased menstruation  and  sterility.  Pain  is  the  most  marked  symptom, 
and  is  felt  most  on  vaginal  examination  or  coitus. 

Physical  Signs. — On  vaginal  examination  obscure  thickening  is  felt  in 
the  fornices.  The  uterus,  if  displaced,  is  often  markedly  anteverted  from 
cicatrization  of  the  peritoneum  in  the  pouch  of  Douglas.  Very  frequently 
it  is  retroverted  and  bound  down  by  adhesions,  which  may,  however,  allow 
of  a  certain  range  of  mobility.  The  chronic  form  remains  often  as  a  sequel 
to  the  acute  ;  but  may  develop  slowly  of  itself. 

DIFFERENTIAL   DIAGNOSIS. 

This  will  be  considered  under  Cellulitis. 

COURSE   AND    RESULTS. 

Very  often  the  inflammatory  condition  clears  up.  The  adhesive  form 
leaves  its  mark  in  the  shape  of  pathological  anteversions,  and  retrover- 
sions  bound  down  (Fig.  119).  The  Fallopian  tubes  may  have  their 
ovum-conducting  power  so  interfered  with  that  an  incurable  sterility 
results.  When  they  are  not  injured  to  this  extent,  conception  may  occur ; 
and  the  adhesions  may  \iltimately  yield  to  the  stretching  brought  to  bear 
on  them  by  the  developing  uterus.  They  may,  however,  resist  this  and 
cause  abortion. 

Occasionally,  pelvic  peritonitis  becomes  general  and  is  then  rapidly 
fatal. 

Serous  exudations  may  become  absorbed ;  pus  may  dry  up,  but  oftener 
perforates  into  the  bladder,  bowel,  or  roof  of  vagina. 

PROGNOSIS. 

Each  case  must  be  judged  on  its  own  merits.     We  give,  therefore, 
ily  .general  hints. 


on 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       165 

As  to  Life. — Pelvic  peritonitis  is  not  usually  fatal.  If  it  becomes  gen- 
eral and  is  septic  or  gonorrhoeal  in  its  origin,  then  the  prognosis  is  very 
grave.  A  high  and  rapid  pulse  of  long  continuance,  with  a  temperature 
not  in  the  same  ratio,  also  makes  prognosis  grave. 

As  to  Sterility. — This  is  difficult  to  give,  and  often  time  alone  settles 
the  point.  The  mechanical  closure  by  pressure  of  the  Fallopian  tube — a 
condition  not  diagnosable — and  ovaritis  rendering  ovulation  impossible, 
are  conditions  often  produced  and  are  both  incurable.  Prognosis  as  to 
conception  should  always  be  cautious,  and  never  absolute  when  the  peri- 
tonitis has  been  extensive. 

TREATMENT. 

A.  Acute  Pelvic  Peritonitis. — a.  Prophylactic. 

b.  General— (1.)    Diet.      (2.)    Septicity. 

(3.)  Pain.     (4)  Pulse  and  Tempera- 
ture. 

c.  Local. 

a.  Prophylactic. — This  is  of  the  very  highest  importance.  The  practi- 
tioner should  always  attend  most  scrupulously  to  antiseptic  cleanliness  in 
all  vaginal,  cervical,  and  uterine  operations.  Cautions  on  these  points  are 
given  under  the  head  of  the  respective  operations,  and  need  not  be  here 
repeated. 

During  their  menstrual  periods  young  patients  should  avoid  all  undue 
fatigue,  late  hours,  violent  exercise,  alternate  exposure  to  heat  and  cold 
when  insufficiently  clad. 

Gonorrhoea  should  be  thoroughly  treated,  especially  during  preg- 
nancy. 

6.  General. — Under  this  we  attend  to  diet,  and  employ  remedies 
intended  to  combat  the  septic  condition  when  present,  to  alleviate  pain, 
and  to  bring  down  pulse  and  temperature. 

(1.)  Diet. — In  the  early  stages  of  inflammation,  this  should  be  chiefly 
milk  iced  or  mixed  with  lime  water,  potash  water  or  lemonade.  Among 
the  better  classes  Apollinaris  or  Seltzer  water  can  be  used.  Seltzer  water 
helps  to  combat  the  constipating  tendency  of  milk  diet. 

When  the  patient's  strength  is  reduced  and  the  pulse  flagging,  nutri- 
tious stimulating  food  must  be  frequently  given.  Milk  should  be  still 
continued  ;  but  beef-tea  or  strong  soups,  every  two  or  three  hours,  must 
be  added.  Stimulants  are  requisite  at  this  stage,  viz.,  brandy,  cham- 


166  MANUAL    OF    GYNECOLOGY. 

pagne,  gin,  or  whiskey.  Care  must  be  taken  to  give  these  in  their 
stimulating  doses,  e.g.,  for  brandy,  a  tablespoonful  every  two  or  three 
hours. 

The  regulation  of  the  bowels  is  not  requisite  in  the  early  stages  ;  but 
in  the  later  periods  must  be  looked  after.  Gentle  aperients,  such  as  com- 
pound liquorice  powder,  colocynth  and  hyoscyamus  pills,  castor-oil,  etc., 
can  be  used ;  and  occasional  enemata  are  of  service.  Enemata  should 
not,  however,  be  used  exclusively,  as  this  may  lead  to  the  formation  of 
troublesome  scybala. 

When  suppuration  is  tedious,  it  should  be  seen  that  no  bed  sores 
form  ;  and  iron  and  quinine  should  be  administered. 

3  •  Ferri  et  Quinise  Citratis gr.  Lone. 

Aquae |  ij. 

Sig.  Teaspoonful  thrice  daily. 

or 

$ .  Ferri  et  Ammonise  Citratis gr.  IXTCT, 

Aquae 1  ij. 

Sig.  Teaspoonful  thrice  daily. 

The  bitterness  is  best  masked  by  dilution  with  water  and  not  with  orange 
or  other  syrups,  which  derange  the  stomach. 

(2.)  To  Combat  any  Septic  Condition. — We  know  no  specific  medicine 
for  this  purpose.  A  favorite  one  is  the  muriate  of  iron  of  the  Edinburgh 
Pharmacopoeia. 

$ .  Tincture  Feni  Muriatis  (Ed.  Phar.) 5  ij. 

Sig.  Thirty  drops  thrice  daily  in  a  glass  of  water.     Water 

should  be  drunk  freely  after  the  dose  is  given,  and  the 

mouth  thoroughly  rinsed. 

Quinine  may  be  used  for  the  same  purpose. 

3  •  Quinise  Sulphatis- gr.  xxiv. 

Acidi  Sulphurici  diluti ".  3  ij. 

Aquam ad  |  vj. 

Sig.  Tablespoonful  thrice  daily  in  water. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       167 

(3.)  To  alleviate  Pain. — Nothing  is  so  good  for  this  as  the  hypodermic 
injection  of  morphia  deep  into  the  deltoid. 

IJ, .  Morphise  Bimeconatis gr.  viij. 

Spiritus  Vini  rectificati Tlliij. 

Aquae f  j. 

Sig.  For  Hypodermic  injection.    Fifteen  minims  contain  ^ 
grain  of  Morphia. 

The  bimeconate  is  a  good  preparation  and  causes  less  sickness  than 
other  forms ;  as  one  drachm  of  this  preparation  contains  one  grain  of 
morphia  and  as  the  hypodermic  syringe  holds  only  30  min.,  it  is  impossi- 
ble to  give  an  overdose  to  an  adult. 

When  doses  larger  than  a  grain  are  needed,  the  hypodermic  solution 
of  the  acetate  of  morphia  (B.  P.)  may  be  employed.  Twelve  minims  con- 
tain 1  grain,  and  therefore  3  minims  is  the  first  dose  for  an  adult. 

It  is  a  good  plan  for  the  practitioner  to  keep  the  ordinary  8  gr.  to  3  j. 
solution,  and  to  prescribe  the  stronger  solution  only  for  any  .patient  re- 
quiring it ;  in  this  way  he  avoids  carrying  two  solutions  of  different 
strength,  by  which  mistakes  might  arise.  The  stronger  solution  is  pre- 
scribed as  follows : — 

IJ.  Injectionis  Morphias  Hypodermicae  (B.  P.) 3  ij. 

Sig.  For  Hypodermic  injection.     Three  minims  contains  £ 
grain  Acetate  of  Morphia. 

Chlorodyne  (25  min.)  ;  Battley's  solution  (liquor  morphise  sedativus, 
25  min.) ;  or  Laudanum  (tinctura  opii,  25  min.)  may  be  used.  More  use- 
ful than  these  are  morphias  suppositories. 

I]L  Morphiae  Hydrochloratis gr.  £ 

Fiat  Suppositor Mitte  tales  yj. 

Sig.  As  directed. 

It  is  a  good  plan  to  quiet  the  pain  rapidly  with  the  hypodermic  injec- 
tion ;  and  to  keep  up  the  good  effect  by  suppository,  in  £  grain  doses 
every  6  hours,  beginning  6  to  8  hours  afterwards.  See  that  the  patient  or 
attendant  understands  that  the  suppositories  are  to  be  passed  into  the 
empty  boweL 


168  MANUAL    OF    GYNECOLOG5T. 

(4.)  To  bring  down  Pulse  and  Temperature. — In  early  stages  tincture  of 
aconite  is  invaluable. 

$.  Tincturse  Aconiti 3  ij. 

Sig.  Six  drops  are  to  be  put  in  a  wine-glass  containing  six 

teaspoonfuls   of  water.      Give  a  teaspoonful  every 

quarter  of  an  hour. 

Drop  doses  of  aconite  are  of  great  value.  They  should  be  given  every 
quarter  of  an  hour  until  the  pulse  is  reduced  and  sweating  brought  on. 

If  this  fail  and  the  temperature  keep  high,  quinine  in  15-grain  doses 
should  be  tried.  The  salicylate  of  quinine  is  a  good  preparation  and  is 
given  just  as  quinine  is.  When  the  stomach  is  irritable  the  quinine,  in 
20-grain  doses,  suspended  in  an  ounce  of  mucilage,  may  be  given  per  rec- 
tum. 

Sometimes  the  ice-cap  is  useful. 

After  the  fever  has  subsided  and  suppuration  is  threatened,  the 
strength  must  be  kept  up  by  tonics  (such  as  quinine  and  iron)  and  by 
nutritious  food  with  a  judicious  amount  of  stimulant,  claret  for  example. 

c.  Local  Treatment. — In  the  early  stages  of  sthenic  nonseptic  cases, 
8  to  10  leeches  may  be  applied  over  the  iliac  regions. 

Ice  is  not  generally  used  as  a  local  application  in  this  country,  and  has 
its  disadvantages. 

Of  greater  use  are  large  hot  linseed  poultices.  They  should  be  made 
very  hot,  a  layer  of  flannel  intervening  between  them  and  the  skin,  and 
should  be  covered  with  a  layer  or  two  of  cotton.  Such  a  poultice  will  be 
effective  for  2  or  3  hours.  Blisters  and  turpentine  stupes  are  good,  but 
soon  render  the  skin  so  sore  that  after-treatment  by  poultices  is  diffi- 
.  cult. 

The  hot  vaginal  douche  (as  directed  at  page  145),  with  carbolic  acid 
added  in  septic  cases,  should  on  no  account  be  omitted. 

Encysted  serous  collections  should,  as  a  general  rule,  be  left  to  be  ab- 
sorbed. When  troublesome  from  pressure,  they  may  be  tapped  by  Mat- 
thieu's  aspirator.  A  clear  serous  fluid,  often  coaguldble,  is  then  drawn 
off,  so  like  urine  that  the  almost  involuntary  first  thought  is  that  the  ope- 
rator has  tapped  the  bladder  by  mistake. 

Pus  does  not  form  so  often  in  pelvic  peritonitis.  It  may  perforate 
into  the  rectum  or  through  the  posterior  fornix.  The  treatment  of  sup- 
puration will  be  best  considered  under  pelvic  cellulitis. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       169 

B.  Treatment  of  Chronic  Pelvic  Peritonitis. — When  adhesions  are  exten- 
sive, the  case  is  better  left  alone.  When  the  uterus  is  retroverted,  it  may 
ultimately  be  replaced  by  bimanual  manipulation.  Massage  is  good  in 


Fig.  119. 

UieruB  retroverted  and  bound  back  by  peritonitic  adhesions  (Winckel).    a  a,  adhesions;  b,  bladder: 
c,  vagina  ;  u,  uterus ;  r,  rectum  (>£). 

such  cases,  but  its  employment  will  be  considered  afterwards  when  we 
speak  of  Weir  Mitchell's  method  of  treatment  by  rest  and  food. 

PELVIC   CELLULITIS. 

SYNONYM. — Parametritis  ;  Parametritis  proper  is  a  term  applied  some- 
times to  inflammation  limited  to  the  cellular  tissue  round  the  cervix  and 
upper  part  of  vagina,  Virchow's  parametric  tissue. 

NATURE. — An  acute  or  chronic  inflammatory  affection,  usually  septic, 
affecting  the  cellular  tissue  of  the  pelvis. 

PATHOLOGICAL    ANATOMY   AND    VAEIETIES. 

It  is  the  rare  exception  to  examine  a  female  pelvis  without  finding 
some  traces  of  a  previous  cellulitis  or  peritonitis.  Thus  split  cervix,  so 
common  in  women  who  have  borne  children,  is  almost  always  associated 
with  some  cellulitis  at  the  base  of  the  broad  ligaments.  The  uterus  is 
rarely  central,  but  is  often  drawn  to  the  one  side  by  the  cicatrization 
of  some  previous  lateral  cellulitic  inflammation  of  the  broad  ligament ; 
the  traction  may  even  be  so  great  that  ic  lies  at  right  angles  to  its  proper 
axis. 

We  have  seen  that  the  utero- sacral  ligaments  are  peritoneal  folds 
containing  connective  tissue  and  unstriped  muscular  fibre.  Inflamma- 


170  MANUAL    OF    GYNECOLOGY. 

tory  attacks  in  one  or  both  of  these  folds  (combined  pelvic  peritonitis 
and  pelvic  cellulitis)  are  very  common.  Schultze  calls  this  '  parametritis 
posterior.'  The  cicatrization  of  these  ligaments  after  such  inflammation, 
causing  traction  just  above  the  isthmus,  brings  about  the  most  common 
cause  of  dysmenorrhoea  and  sterility — pathological  anteflexion  of  the 
uterus  (v.  Anteflexion  of  the  Uterus).  It  is  evident  that  in  this  way,  too, 
we  get  the  uterus  anteflexed  and  drawn  to  one  side  or  anteflexed  and 
drawn  back  (Fig.  40). 

Sometimes,  pelvic  abscesses  are  found  in  localities  to  be  afterwards 
alluded  to.  Often  the  uterus  and  ovaries  are  in  an  atrophic  condition 
owing  to  compression  of  the  vessels  and  nerves  by  the  cellulitic  attack ; 
this  quite  agrees  with  the  clinical  fact  that  many  women  with  bad  path- 
ological anteflexion  do  not  suffer  much  at  their  periods,  because  the 
withered  condition  of  the  organs  produces  scanty  menstruation.  Freund 
has  written  on  a  peculiar  condition  under  the  term  "Parametritis  chro- 
nica  atrophicans  " ;  he  asserts  that  we  have  a  chronic  inflammatory  con- 
dition, ultimately  causing  atrophy  by  compression  of  blood-vessels  :  per- 
haps this  may  be  a  final  stage  of  cellulitis.  According  to  some,  we  can 
have  no  cellulitis  in  the  broad  ligaments  and  no  formation  of  pus — abscess 
of  the  broad  ligaments.  Clinical,  anatomical,  and  pathological  evidence  is 
in  favor  of  the  occurrence  of  both.  At  the  same  time,  it  is  almost  impos- 
sible clinically  to  distinguish  abscess  of  the  broad  ligament  from  an  en- 
cysted serous  pelvic  peritonitis  behind  it,  pushing  it  forwards. 

ETIOLOGY. 

In  parous  women  the  great  cause  of  pelvic  cellulitis  is  septic  matter 
absorbed  by  the  lymphatics  from  the  torn  perineum,  vagina,  or  cervix. 
This  passes  along  the  abundant  lymphatics  in  the  cellular  tissue  beneath 
and  in  the  broad  ligaments,  causing  inflammation  of  the  glands  and 
proliferation  of  the  connective  tissue  in  which  these  are  embedded. 
Thus  we  find  childbirth,  premature  labor,  and  abortion  often  followed 
by  cellulitic  attacks,  for  obvious  reasons.  In  parturition  we  have  the 
cervix,  for  instance,  torn  vertically  at  one  side ;  and  septic  matter  de- 
posited there  often  speedily  spreads  along  the  lymphatic  stream.  Steurer, 
who  investigated  an  epidemic  of  puerperal  fever  at  Strasburg,  found 
such  cases  with  diphtheritic  patches  about  the  vulva ;  and  from  these 
traced  bacteria  into  the  connective  tissue  spaces  where  their  presence 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       171 

gave  rise  to  cellulitis ;  from  the  spaces  they  entered  the  lymphatics  caus- 
ing lymphangitis. 

Klebs,  who  terms  the  bacteria  found  in  a  wound  "  microsporon  septi- 
cum,"  traced  their  penetration,  with  or  without  the  aid  of  wandering 
white-blood  corpuscles,  from  serous  membranes  into  the  connective  tissue, 
and  noted  their  penetration  through  the  eroded  wall  of  a  vein. 

Recklinghausen  found  the  lymphatics  of  the  skin,  at  the  edge  of  an 
erysipelatous  patch,  filled  with  bacteria. 

Still  more  recently,  Koch  has  investigated  the  relation  of  bacteria  and 
micrococci  to  traumatic  infective  diseases  in  his  recent  monograph  trans- 
lated by  Watson  Cheyne.  It  is  well  worth  perusal. 

The  practical  result  of  all  this  is  that,  in  gynecological  operations  and 
abortions,  all  wounds  must  be  kept  strictly  clean  ;  and  that  Listerism, 
when  possible,  should  be  carried  out  (u.  Ovariotomy  and  Treatment  of 
Pelvic  Abscess).  The  student  will,  as  he  proceeds,  see  endless  applications 
of  these  results. 

In  nulliparce,  cellulitis  may  arise  from  the  same  causes  as  are  given 
under  pelvic  peritonitis,  e.g.,  exposure  to  cold  during  menstruation. 

Pelvic  peritonitis,  in  a  minor  degree,  is  always  associated  with  cellulitis 
for  reasons  already  given.  So  far  as  we  have  considered  the  etiology  of 
pelvic  inflammatory  affections,  we  have  associated  them  with  some  virus, 
most  frequently  septic.  We  do  not  believe  that  mere  traumatic  injury, 
apart  from  septicity  and  tension,  can  cause  any  inflammatory  attack. 

SYMPTOMS. 

The  patient  has  a  rigor  or  chill.  Pain  is  felt  over  the  lower  part  of 
the  abdomen,  but  it  is  not  so  intense  as  in  peritonitis.  The  pulse  and 
temperature  are  raised.  Often  after  exudation  has  taken  place,  the  patient 
has  one  thigh  alone  drawn  up. 

PHYSICAL    SIGNS. 
l 

There  is  pain  on  palpation  of  the  abdomen  ;  and  after  exudation  has 
taken  place,  we  feel  a  fulness  at  one  side  of  the  uterus  or  in  the  iliac  fossa. 

Bimanual  examination,  always  difficult,  reveals  at  first  nothing  but  in- 
creased heat  and  tenderness.  After  exudation  has  occurred,  it  is  found  in 
the  following  positions : 

(1.)  As  a  bulging  at  the  side  of  the  uterus,  depressing  the  lateral  fornix 
and  pushing  the  uterus  usually  to  the  other  side  ; 


172  MANUAL    OF    GYNECOLOGY. 

(2.)  In  the  upper  portion  of  the  broad  ligament,  and  therefore  not 

bulging  downwards ; 
(3.)  In  the  iliac  fossa  ; 
(4.)  Very  rarely,  behind  the  uterus  ; 
(5.)  Almost  never,  between  uterus  and  bladder. 

We  have  seen  pus  pointing  in  the  inguinal  region  on  one  side,  and 
with  no  dipping  down  into  the  pelvis  or  intermediate  connection  with  the 
side  of  the  uterus.  When  pus  is  present  in  large  amount,  the  fluctuation 
can  be  felt  bimanually.  When  it  forms  in  the  centre  of  a  large  inflamma- 
tory exudation,  an  obscure  boggy  feeling  may  or  may  not  be  made  out. 
Aspiration  helps  here  very  much. 

The  course  of  these  exudations,  inflammatory  or  purulent,  is  explained 
in  two  ways. 

(a.)  By  the  course  of  the  lymphatics,  which  run,  as  we  have  seen,  from 
the  uterus  outwards,  beneath  and  between  the  layers  of  the  broad  liga- 
ment to  the  glands  in  the  lumbar  region. 

(6.)  By  the  lines  of  cleavage  in  the  cellular  tissue  of  the  pelvis.  The 
student  should  refer  back  to  Konig's  researches  (page  48).  Based  on 
these,  and  on  clinical  work,  Konig  asserts  that — 

(1.)  An  exudation  in  the  broad  ligament,  near  the  tube  and  ovary,  passes 
first  along  the  psoas  and  iliacus  and  then  sinks  into  the  true 
pelvis  : 

(2. )  Exudations  which  begin  primarily  in  the  deeper  cellular  tissue  on 
the  antero-lateral  aspect  of  the  cervix,  pass  first  on  to  the  cellu- 
lar tissue  of  the  true  pelvis  at  the  side  of  the  uterus  and  bladder  ; 
and  then  pass  with  the  round  ligament  to  Poupart's  ligament 
beneath  the  inguinal  canal ;  thence  they  pass  outwards  and 
backwards  into  the  iliac  fossa : 

(3.)  Abscesses,  developing  from  the  posterior  aspect  of  the  broad  liga- 
ments, fill  first  the  postero-lateral  part  of  the  pelvis  and  then 
pass  as  in  (1). 

DIFFERENCES   AND   DIFFERENTIAL   DIAGNOSIS   BETWEEN    PELVIC   PERITONITIS   AND 

CELLULITIS. 

Differences. 

Pelvic  Peritonitis.  Pelvic  Gellulitis. 

(1.)  Inflammatory  affection  of  (1.)  Inflammatory  affection  of 
pelvic  peritoneum  chiefly.  pelvic  cellular  tissue  chiefly. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       1  73 

(2.)  Usually  general,  round  the  (2.)  Usually  lateral, 

uterus. 

(3.)  Not  always  septic.  (3.)  Usually  septic. 

Differential  Diagnosis. 

(1.)  Pain  very  severe.  (1.)  Pain  not  so  severe. 

(2,. )  Patient's  legs  drawn  up  on  (2. )  Usually,  only  one  leg  drawn 

both  sides.  up. 

(3. )  Firm  flat  effusion  not  bulg-  (3.)  Firm  effusion,  bulging  usu- 

iug  into   fornices,    and  round    the  ally  into  fornix  of  one  side.     Thus 

uterus.   Symmetrical  bulging  of  ser-  cervix  (vaginal  portion)  apparently 

ous  effusion  behind  uterus.     Cervix  shortened  on  one  side, 
(vaginal  portion)  is  normal  length. 

(4.)     Does     not     spread     along  (4.)  Exudation  or  pus  spreads 

round  ligament  or  into  iliac  fossa,  in  definite  directions,  and  is  usually 

but  may  affect  all  peritoneum.  localised. 

(5.)  Uterus  displaced   to   front,  (5.)  Uterus  usually  displaced  to 

or  unaltered  in  position  one  side. 

(6.)  Vomiting  more  frequent.  (6.)  -Vomiting  less  frequent. 

It  is  often  very  difficult  to  differentiate  these  ;  and  therefore  in  some 

cases  the  diagnosis  must  be  pelvic  inflammation,  probably  cellulitic  or 
peritonitic,  as  the  case  may  be. 

COURSE  AND  RESULTS. 

Very  often  the  attack  passes  off  and  leaves  no  trace.  The  septic  poison 
is  too  small  in  amount  to  do  harm  ;  or  it  sets  up  some  inflammatory  exu- 
dation, which  mechanically  arrests  progress,  and  then  becomes  absorbed. 
The  vitality  or  health  of  the  tissue  and  the  strength  of  the  poison  have 
also  their  share  in  determining  its  progress.  Exudation  may  take  place 
and  may  be  absorbed  almost  completely,  may  suppurate  slowly  and  only 
to  a  limited  extent,  or  may  form  a  large  abscess.  This  abscess  may  open 
into  the  bowel  or  bladder,  or  pass  below  Poupart's  ligament,  or  upwards 
beneath  the  kidney.  Karely  does  it  appear  in  the  perineum,  or  pass  through 
the  sciatic  notch  to  the  buttock.  In  one  case  where  the  last  occurred,  the 
patient  complained  of  a  very  deep-seated  pain  just  over  the  notch. 

It  is  valuable  to  note  how  rarely  the  abscess  perforates  into  the 
peritoneal  cavity.  The  peritoneal  surfaces  of  the  abdominal  contents  are 
in  contact ;  and  as  the  inflammatory  attack  spreads,  it  sets  up  a  peritonitis, 


174  MANUAL    OF    GYNAECOLOGY. 

gluing  the  adjacent  surfaces  together.     When  pus  does  enter  the  peri- 
toneum, it  sets  up  a  rapidly  fatal  peritonitis. 

PROGNOSIS. 

This  depends  on  the  extent  of  the  inflammatory  attack,  and  its  effect 
on  the  patient's  health.  Its  septic  origin  usually  causes  anxiety  ;  but  it 
does  not  spread  so  rapidly  as  peritonitis.  Eesolution  of  inflammatory 
deposits  is  slow.  Pathological  anteflexion  gives  rise  to  troublesome 
dysmenorrhoea  and  sterility.  Prognosis  should  always  be  guarded  as 
to  complete  recovery. 

TREATMENT. 

The  general  and  the  local  treatment  are  exactly  the  same  as  in  pelvic 
peritonitis.  The  occurring  of  suppuration  is  indicated  by  rigors  and 
should  be  hastened  by  the  hot  douche  and  poultices.  We  may  have 
only  part  or  parts  of  the  exudation  suppurating,  so  that  in  a  cellulitic 
swelling  we  may  have  inflammatory  exudation  containing  separate  abscess 
cavities.  In  these,  tapping  with  Matthieu's  aspirator  is  very  good,  and 
may  be  often  repeated.  Care  should  be  taken  that  the  aspiratory  needle 
has  been  purified  in  carbolic  lotion  (1-20),  and  prior  to  introduction  dipped 
in  carbolic  oil  (1-20). 

When  pus  is  present  in  large  quantity,  the  treatment  varies  according 
to  the  part  at  which  it  points. 

(1.)  If  it  point  below  Poupart's  ligament,  in  the  buttock,  or  behind  the 
kidney,  it  is  to  be  opened  under  Listerism  and  a  drainage-tube  inserted. 
Results  by  this  method  are  admirable. 

(2. )  If  it  bulge  in  the  vaginal  roof,  it  should  be  opened  as  follows : 
Pass  Sims'  speculum,  and  open  into  the  cavity  with  Paquelin's  cautery  at 
a  dull  heat ;  make  the  opening  big  enough  to  admit  two  good  sized 
drainage-tubes.  Daily  irrigate  the  cavity  with  weak  carbolic  lotion  (1-100) 
or  boracic  lotion  (1-30).  If  the  discharge  is  profuse  it  may  be  received 
into  pads  of  salicylic  cotton-wool  placed  over  the  vulva  ;  oakum  or  marine 
lint  may  be  used  among  poor  people. 

The  drainage-tubes  should  be  double,  and  with  a  small  piece  at  the 
end  at  right  angles,  which  prevents  them  slipping  out.  They  should  not 
be  perforated,  as  this  prevents  the  washing  out.  If  only  straight  tubes 
can  be  had,  a  small  piece  of  ivory  can  be  stitched  to  the  upper  end. 

During  suppuration,  tonics  and  nutritious  diet  should  be  given. 


CHAPTER  XVI. 

PELVIC  KZEMATOCELE. 

• 

LTTERATUKE. 

Aitken,  LaiuMan — Case  of  Pelvic  Haematocele  :  Ed.  Med.  J.,  1862,  p.  104.  Bandl — 
Op.  cit.  Bernutz  and  Gouptt—Op.  cit.  Barnes — Op.  cit.,  p.  590.  Bourdon — 
Tumeurs  fluctuants  du  petit  bassin  :  Rev.  Med. ,  1841.  Crede — Monatsschrift  f. 
Geburtskunde,  Bd.  IX. ,  S.  1.  Duncan,  Mathews — Uterine  Haematocele :  Ed.  M. 
J.,  1862,  p.  418:  Clinical  Lectures,  Churchill,  Lond.,  1879.  Fritsch—Vie  Re- 
tro-uterine Hsematocele :  Volkmann's  Sammlung  No.  56.  KuTtn — Ueber  Blnter- 
giisse  in  die  breiten  Mutterbander  und  in  das  den  Uterus  umgebenden  Gewebe  : 
Zurich,  1874.  M'Clintock— Diseases  of  Women:  1858.  Nelaton— Gaz.  des  Hopi- 
taux,  1851  and  1852.  PeUetan— Clinique  Chirurgicale,  Paris,  1810.  Priestley, 
W.  0.— Pelvic  Haeraatocele :  Reynolds'  System  of  Med.,  Vol.  V.,  p.  783.  Simp- 
ion,  J.  T.  —Peri-uterine  or  Pelvic  Hsematocele,  Collected  Works,  Vol.  III.,  p. 
121:  A.  &C.  Black,  Edinburgh.  Schroeder—Op.  cit.,  S.  453:  Kritische  Unter- 
suchungen  iiber  die  Diagnose  der  Haematocele  Retro-uterina  :  Arch.  f.  Gyn.,  Bd. 
V.  Tilt — Pathology  and  Treatment  of  Sanguineous  Tumours,  Lond.,  1853. 
Vomn— De  1'  hematoc51e  Retro-uterine  :  These,  Paris,  1858.  The  literature  is 
well  given  in  Bandl's  work  and  Priestley's  article. 

SYNONYMS — Ketro-uterine  Hsematocele  :  Uterine  Hsematocele. 

THIS  subject  will  be  considered  under  the  same  heads  as  the  preceding. 

Preliminary  Considerations. — The  abundant  venous  supply  of  the  pel- 
vic organs,  the  congestion  induced  by  menstruation,  and  the  hemorrhage 
accompanying  the  monthly  rupture  of  the  Graafian  follicle,  render  women 
peculiarly  liable  to  hemorrhages  into  the  pelvic  cavity.  Yet  it  is  astonish- 
ing that  it  is  only  since  1850  that  this  subject  has  really  attracted  gyne- 
cologists' attention.  It  was  in  that  year  that  Nelaton  gave  the  subject  due 
prominence ;  although  Voisin  (1810),  Kecamier,  Bourdon  (1841),  Ollivier, 
and  Bernutz  had  all  recorded  cases,  under  such  titles  as  "  Blood-gush  from 
an  Aneurism  of  the  Ovary,"  "  Blood-Cysts  of  the  Pelvic  Cavity."  Nelaton 
had  diagnosed  his  case  as  nn  abscess,  and  opened  it  with  a  bistoury  ;  the 
blood  and  blood-clots  escaping  from  the  incision  showed  its  real  nature 


17G  MANUAL    OF    GYNECOLOGY. 

unmistakably.  Since  that  time,  pelvic  hsematocele  1ms  taken  its  place  in 
gynecology  as  a  serious  and  important  symptom. 

NATURE. — An  effusion  of  blood,  usually  into  the  pelvic  peritoneum,  some- 
times beneath  it ;  enclosed  either  by  anatomical  structures  or  previously  exist- 
ing inflammatory  adhesions. 

Many  will  consider  this  definition  unsatisfactory  ;  it  must  be  taken, 
however,  in  connection  with  the  following  remarks.  Pelvic  hsematocele 
is  not  a  disease.  It  is  only  a  symptom  of  some  previously  existing  patho- 
logical condition  of  the  pelvic  organs,  just  as  haemoptysis  is  not  a  disease 
but  usually  a  symptom  of  some  lung  condition.  We  have  limited  the 
term  hsematocele  to  haemorrhages  into  the  pelvic  cavity. 

It  is  disputed  whether  the  inflammation  encysting  and  limiting  the 
hemorrhage  is  antecedent  or  consequent  to  it.  The  former  view  has 
much  more  evidence  in  its  favour,  although  some  cases  support  the  latter. 
This,  however,  belongs  more  especially  to  pathological  anatomy. 

It  may  be  urged  that  we  have  limited  the  term  pelvic  hsematocele  to 
hemorrhages  enclosed  by  anatomical  relations  or  inflammatory  adhesions. 
We  do  this,  however,  for  the  following  reason.  The  hemorrhage  gives  no 
physical  sign  until  enclosed,  and  is  no  more  palpable  to  the  finger  exam- 
ining through  the  fornices  than  the  intestines  or  ascitic  fluid  are.  Fluid 
blood  in  the  pelvis  can  only  be  diagnosed  by  abdominal  incision  or  post- 
mortem. 

PATHOLOGICAL   ANATOMY. 

Post-mortem  cases  are  rare,  but  enough  have  been  recorded  to  give  us 
some  idea  of  its  pathology. 

In  almost  all  the  cases,  the  blood  is  found  enclosed  by  pelvic  inflam- 
matory adhesions,  apparently  antecedent.  Dr.  Lauchlan  Aitken  has  re- 
corded a  case  which,  during  life,  presented  the  usual  physical  signs  of 
retro-uterine  Lrematocele,  viz.,  a  retro-uterine  tumour  bulging  into  the 
posterior  fornix  vaginse  and  displacing  the  uterus  markedly  forward  ;  And 
in  which,  on  post-mortem,  clotted  blood,  not  enclosed  by  adhesions,  was 
found  behind  the  uterus. 

Usually,  however,  the  tumour  when  retro-uterine  has,  as  its  bound- 
aries, the  uterus  and  broad  ligaments  in  front  and  the  sacral  peritoneum 
behind  ;  while,  above,  it  is  roofed  in,  as  it  were,  by  adherent  intestine  or 
by  the  retroverted  and  adherent  uterus.  The  uterus  is  markedly  driven 
forward  by  the  effusion. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       177 

Sometimes  the  blood  is  found  effused  between  the  layers  of  the  broad 
ligament,  which  limits  it  unless  the  effusion  is  so  great  as  to  perforate  a 


Fig.  120. 
Retro-uterine  haematocele.    Pouch  of  Douglas  previously  obliterated  by  inflammation. 

lamella  and  escape  into  the  peritoneum.  Occasionally  the  blood  is  below 
the  peritoneum  and  dissects  it  up  as  it  escapes  from  the  vessels  ;  or  it  is 
found  in  the  cellular  tissue  of  the  pelvis. 


Fig.  121. 

Retro-ntcrine  hsematocele.    Pouch  of  Douglas  not  previously  obliterated  (Schroeder). 

It  is  of  the  highest  pathological  importance  to  note  that  in  a  very 
large  proportion  of  the  cases  diseased  ovaries  have  been  found  ;  changes 


178  MANUAL    OF    GYNECOLOGY. 

in  the  Fallopian  tubes  (dilatation  and  filling  with  blood  or  pus)  being  less 

common. 

The  effused  blood  undergoes  changes  in  course  of  time,  so  that  blood- 
crystals,  granular  corpuscles  and  oil  drops  are  found  as  traces  of  the 
previous  blood  effusion.  When  the  patient  dies  soon  after  the  hemor- 
rhage, the  blood  is  merely  clotted.  In  most  cases  of  recovery  it  becomes 
entirely  absorbed. 

ETIOLOGY SOUECES    OF    HEMORRHAGE    AND   VARIETIES. 

The  table  quoted  below  shows  that  pelvic  haematocele  is  most  common 
in  women  between  the  ages  of  25  and  35,  that  is,  women  in  their  period 
of  full  menstrual  and  sexual  vigor.  Out  of  43  cases,  the  ages,  according 
to  Schroeder,  were  as  follows : — 

In    3  cases,  or    7.0  p.  c.,  the  ages  were  22-25 

"  14         "        32.5     "  "  25-30 

"  13         "        30.2     "  "  30-35 

"    9         "        20.9     «  "  35-40 

"     3         "          7.0     "  "  40-43  ; 

"     1         "          2.2     "  "  53 

It  is  also  most  common  in  multipart,  and  occurs  in  about  4  or  5  per 
cent,  of  specially  female  diseases. 

The  following  are  the  chief  causes  of  hemorrhage,  and  its  anatomical 
sources  : 

1.  Predisposing  Causes. — Profuse  menstruation  ;  violent  exercise  during 
menstruation,    such   as   dancing ;    violent   coitus   during   menstruation  ; 
varicose    conditions   of    the   subperitoneal   veins ;    purpura ;    scorbutus ; 
hseinophila. 

2.  Anatomical  Sources. — (a.)  Pelvic  Peritoneum. — There  may  be  rupture 
of  veins  of  the  pampiniform  plexus,  or  of  the  veins  below  the  uterine 
peritoneum.     In  the  former  case,  we  may  get  the  blood  pouring  directly 
into  the  peritoneum  ;  or  first  passing  between  the  layers  of  the  broad 
ligament,  and  either  remaining  enclosed  there  or  rupturing  into  the  peri- 
toneum.    The  hemorrhage,  according  to  Virchow,  may  arise  from  vessels 
developed  in  the  false  membranes  of  pelvic  peritonitis.     Crede,  of  Leipzig, 
quotes  a  case  where  he  tapped  a  tumor  and  first  got  serum,  then  blood- 
stained serum,  and  finally  bipod.     In  two  days,  a  fresh  tapping  first  gave 
putrid  blood  and  then  fresh  blood  in  abundance. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       179 

(b.)   Connective  Tissue. — Rupture  of  veins  occurs  here  also. 

(c.)  Uterus. — We  may  have  regurgitation  in  menorrhagia  from  the 
uterus  along  the  dilated  Fallopian  tubes.  Rupture  of  interstitial  extra- 
uterine  pregnancy  is  another  cause  of  hemorrhage. 

(d.)  Fallopian  Tube. — Blood  may  come  from  its  hypenemic  mucous 
membrane.  More  usually  it  arises  from  rupture  of  an  extra-uterine  preg- 
nancy there. 

(e.)  Ovary. — Here  it  results  from  rupture  of  congested  vessels,  of  the 
Graafian  follicles,  or  of  extra-uterine  pregnancy  in  Graafian  follicles. 

Of  all  these  causes,  rupture  of  veins  below  the  peritoneum,  and  rupture 
of  Fallopian  tube  and  ovarian  pregnancies  are  the  most  common.  The 
student  will  now  clearly  see  the  symptomatic  nature  of  heematocele. 

Varieties. — We  have  adopted  "  pelvic  hsematocele "  as  a  convenient 
general  term.  When  the  blood  effusion  is  retro-uterine  and  intra- 
peritoneal,  then  "  retro-uterine  hsematocele  "  is  the  term  usually  employed. 


Fig.  122. 
Copious  Mood-effusion  ante  and  ret  ro  uterine. 

In  cases  where  the  blood  effusion  is  copious,  it  may  flow  up  to  the  an- 
terior fornix,  "  ante-uterine  hsematocele  ; "  when  beneath  the  peritoneum 
— extra-peritoneal — and  extensive,  it  may  be  termed  *'  peri-uterine."    An 
effusion  into  the  connective  tissue  is  conveniently  termed  hcematoma. 
All  these  may  be  classed  under  two  heads,  viz. : — 

1.  Intra-peritoneal,  i.e.,  blood  effusion  into  the  pelvic  peritoneum  ; 
the  most  common  class. 


180  MANUAL    OF    GYNECOLOGY. 

2.  Extra-peritoneal,  i.e.,  blood  effusion  beneath  the  peritoneum, 
between  the  layers  of  the  broad  ligament  or  deep  in  the 
connective  tissue. 

SYMPTOMS. 

The  chief  symptoms  are  menorrhagia,  sudden  onset,  sudden  bloodless- 
ness,  pain.  The  pulse  may  become  feeble  from  anaemia,  and  the  tem- 
perature is  not  above  normal.  Menorrhagia  is  not  always  present,  and 
the  bloodlessness  may  not  be  very  well  marked  ;  sometimes  patients  have 
a  sudden  faint  feeling.  In  cases  of  copious  effusion  from  rupture  of  an 
extra-uterine  pregnancy,  the  symptoms  are  often  like  those  of  irritant 
poisoning,  viz.,  sudden  onset,  prostration,  vomiting.  The  marked  anaemia, 
however,  points  to  some  internal  hemorrhage  ;  inquiry  should  then  be 
made  as  to  menstruation,  and  this  always  followed  by  bimanual  exam- 
ination. 

In  retro-uterine  haematocele,  we  find  frequent  painful  micturition  and 
difficulty  in  evacuation  of  the  bowels.  There  is  no  retention  of  urine. 

• 

PHYSICAL   SIGNS. 

These  are  sometimes  negative  ;  often  characteristic,  especially  in  retro- 
uterine  hsematocele. 

Blood  effused  into  the  pelvic  peritoneum,  and  neither  coaguluted  nor 
enclosed  by  adhesion,  is  not  palpable  to  examination,  and  does  not  cause 
the  pouch  of  Douglas  to  bulge  downwards  (Fig.  123).  It  will  be  pressed 
out  of  the  pouch  of  Douglas,  as  the  bladder  distends,  and  return  into 
it  when  it  empties.  It  is  often  said  that  the  effused  blood  naturally 
gravitates  into  the  pouch  of  Douglas.  It  does  not  do  so.  It  lies  in  the 
pouch  of  Douglas  only  because  it  has  been  effused  near  it  ;  and  it  causes  the 
pouch  of  Douglas  to  bulge  down  only  when  it  is  effused  below  adhesions 
which  limit  its  spreading  up.  Blood  has  a  specific  gravity  of  1055,  and 
remains  where  it  has  been  effused.  Yet  effused  blood  is  often  spoken  of 
as  if  it  were  lead,  sinking  down  whenever  it  got  out  of  the  blood-vessels. 

When,  however,  blood  is  poured  out  near  the  pouch  of  Douglas  and 
below  adhesions,  we  get  the  following  characteristic  state.  On  abdominal 
palpation,  a  tumour  may  be  felt.  On  vaginal  examination  a  firm  convex 
bulging  tumour  is  felt,  varing  in  size  from  a  billiard-ball  to  a  child's  head 
and  sometimes  filling  up  a  large  part  of  the  pelvic  cavity  ;  the  os  uteri  is 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       181 

pressed  close  behind  the  symphysis,  looks  downward  and  is  often  almost 
inaccessible  (Fig.  121).  A  good  plan  to  get  at  it  is  to  turn  the  index  finger 
palmar  surface  to  the  symphysis,  and  push  it  well  up.  On  bimanual  ex- 
amination, the  fundus  uteri  is  felt  usually  distinct,  just  below  the  abdominal 


Fig.  123. 
Free  blood  not  causing  pouch  of  Douglas  to  bulge  down. 

ivalls,  just  behind  the  symphysis,  and  generally  to  one  or  other  side.  This 
settles  the  point  that  the  retro-uterine  tumour  is  not  the  uterus.  The 
sound  confirms  the  bimanual  as  to  the  position  of  the  uterus,  but  is  not 
as  a  rule  necessary. 

When  the  effusion  is  into  the  broad  ligament  the  exact  diagnosis  is 
more  difficult.  Such  cases  are  usually  found  on  post-mortem  or  operation. 
During  life,  reliance  must  be  placed  on  symptoms,  viz.,  sudden  occurrence, 
and  absence  of  inflammation  at  first.  The  physical  signs  in  large  peri- 
uterine  effusions  are  that  the  bulging  is  round  the  uterus,  and  that  it  is 
not  confined  to  the  pouch  of  Douglas.  Hcematoma  is  difficult  to  diagnose, 
and  is  probably  often  mistaken  for  a  cellulitic  deposit. 

When  the  blood  effusion  is  large,  the  patient  may  sink  before  any  very 
definite  physical  signs  are  found.  We  have  taken  the  view  that  pelvic 
peritonitis  is  usually  antecedent  to  the  hsematocele.  At  the  same  time 
we  always  have  a  resulting  peritonitis  coming  on  in  a  day  or  two,  this 
being  indicated  by  increased  pulse  and  temperature  and  by  tenderness  on 
pressure. 


182  MANUAL    OF    GYJSTECOLOGY. 

All  that  has  been  given  here  is  only  how  to  diagnose  the  symptom  of 
the  occurrence  of  hemorrhage.  The  diagnosis  of  the  condition  causing  the 
hemorrhage  is,  unless  in  the  case  of  extra-uterine  pregnancy,  as  yet 
beyond  our  clinical  knowledge. 

DIAGNOSIS    AND   DIFFERENTIAL    DIAGNOSIS. 

Pelvic  hsematocele  requires  to  be  diagnosed  from — 

Pelvic  peritonitis  followed  by  enclosed  serous  effusion  in  pouch  of 
Douglas, 

Pelvic  cellulitis, 

• 

Fibroid  on  posterior  wall  of  uterus. 

Ovarian  cyst  behind  uterus, 

Extra-uterine  pregnancy, 

Retention  of  blood  in  horn  of  maldeveloped  uterus, 

Retroversion  of  non-gravid  or  gravid  uterus. 

Of  these  we  consider  at  present  only  pelvic  peritonitis  and  pelvic  cel- 
lulitis. 

In  these  two  purely  inflammatory  affections  we  have  the  inflammatory 
symptoms  from  the  first,  without  a  history  of  sudden  onset  or  of  menor- 
rhagia.  Further,  the  difference  in  etiology  of  haematocele  and  peritonitis 
will  help  us.  The  history  is  of  the  greatest  service. 

i 

COURSE   AND   RESULTS. 

In  many  cases  (four-fifths  according  to  Voisin)  the  blood  effused  be- 
comes entirely  absorbed,  in  a  time  varying  from  2  to  10  months. 

The  tumour,  with  partially  clotted  or  purulent  contents,  may  burst 
into  the  rectum,  vagina  or  peritoneal  cavity  :  in  the  last  case,  fatal  peri- 
tonitis follows. 

When  the  blood  effusion  is  very  large,  death  may  be  rapid. 

PROGNOSia 

As  to  Life. — This  is,  as  a  rule,  settled  soon.  The  most  fatal  cases  aro 
extra-uterine  pregnancies,  and  rupture  of  varicose  vein  into  the  peritoneum 
with  no  peritonitic  adhesions  to  limit  the  blood  effusion.  After  peritonitis 
is  set  up,  the  prognosis  is  much  as  in  pelvic  cellulitis. 


AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE  TISSUE.       183 

TREATMENT. 

(1.)  At  onset  of  hemorrhage. 
(2.)   When  suppuration  occurs. 

(1.)  At  Onset  of  Hemorrhage. — The  treatment  here  is  expectant.  The 
atient  is  to  be  put  at  complete  rest,  with  ice-bags  to  the  abdomen. 
Ergotine  should  be  injected  into  the  buttock.  If  the  patient  is  collapsed, 
then  stimulants  and  hypodermic  injections  of  sulphuric  ether  or  whiskey 
must  be  freely  used.  In  most  cases,  the  source  of  the  bleeding  is 
unknown  ;  the  present  state  of  knowledge  does  not  enable  us  to  lay  down 
any  rule  as  to  the  opening  of  the  abdominal  cavity  and  the  attempt  to 
ascertain  and  secure  the  bleeding  source.  In  Fallopian  tube  pregnancies 
which  have  burst,  the  abdomen  has  been  incised  and  the  tube  ligatured 
on  either  side  of  the  rupture  ;  but  no  case  of  cure  has  been  reported  so 
far  as  we  know.  The  plan  of  incising  the  retro-uterine  tumour  and  clear- 
ing out  clots  is  wrong  ;  it  simply  leads  to  more  bleeding  from  rupture  of 
adhesions.  When  absorption  is  going  on,  the  treatment  is  just  as  in 
pelvic  peritonitis. 

(2.)  After  Suppuration  has  occurred. — The  tumour  is  to  be  opened  and 
drained,  as  recommended  at  p.  174  for  suppurating  pelvic  cellulitis. 

Recently,  Mr.  Lawson  Tait  has  recommended  that  some  pelvic  abscesses 
be  opened  by  abdominal  section,  as  we  often  get  very  tedious  cases  when 
they  perforate  into  the  bowel.  The  following  was  the  treatment  in  one  of 
six  cases  in  which  he  performed  it.  "I  determined  to  open  it  from  above. 
.  .  .  I  found  a  large  cavity  containing  about  two  pints  of  fetid  pus 
with  decomposing  blood-clots.  This  I  carefully  cleansed  out,  and  after 
having  united  the  edges  of  the  opening  into  the  cyst  carefully  to  the  ab- 
dominal wound,  I  fixed  in  one  of  Koeberle's  drainage-tubes  five  inches 
long.  .  .  .  The  patient  went  home  cured  on  the  30th  day." 

Tait's  cases  were  chiefly  suppurating  hzematoceles  (Tr.  of  Lond.  Merl. 
Chir.  Soc,  vol.  62). 


SECTION  IV. 

AFFECTIONS   OF  THE   FALLOPIAN  TUBES  AND 

OVARIES. 

CHAPTER  XVII.  Fallopian   Tube ;     Parovarium  ;     Round  Ligameni ; 

Broad  Ligament ;  Tubo-ovarian  Cysts. 
"        XVIII.   Malformations  of  Ovary ;   Ovaritis  and  Periovaritis  ; 

Displacements  of  Ovary — Hernia ;  Prolapsus. 
XIX.   Battey's  Operation. 
"  XX.   Pathology  of  Ovarian  Tumours. 

"          XXI.    Diagnosis  of  Ovarian  Tumours. 
"        XXII.   Operative  Treatment  of  Ovarian  Tumours. 


CHAPTER  XVII. 

FALLOPIAN   TUBE;     PAEOVABIUM;    BOUND  LIGAMENT;    BROAD 
LIGAMENT;  TUBO-OVAEIAN  CYSTS. 

LITERATURE. 

Bandl—Op.  cit.  Barnes — Op.  cit.,  p.  376.  Hennig — Krankheiten  der  Eileter  und  die 
Tubarschwangerschaft :  Stuttgart,  18T6.  Duncan — Clinical  Lectures  :  Lond., 
1879.  Kiob— Pathologische  Anatomic  der  weiblichen  Sexualorgane  :  Wien,  1864. 
Noeggeralh— The  Vesico- vaginal  and  Vesico-rectal  Touch  :  Am.  J.  of  Obst.,  VIII.. 
p.  123.  Simpson,  J.  Y.—  Op.  cit,  p.  539.  Schroeder—Op.  cifc.,  S.  329.  Tait— 
Menstrual  Fluid  retained  in  the  Left  Fallopian  Tube  simulating  Ovarian  Tumour  : 
Br.  Med.  J.,  1878,  p.  677.  T/iomas—Op.  cit.,  p.  760.  Williams— Ovarian  Tumours: 
Reynolds'  System  of  Medicine,  Vol.  V.  Wells,  T.  8. — Diseases  of  Ovaries  :  Lon- 
don, 1873.  For  other  literature  see  Bandl,  whose  work  and  that  of  Hennig  w<? 
mainly  follow. 

FALLOPIAN  TUBE. 

Preliminary  Considerations. — The  anatomical  relations  of  the  Fallopian 
tubes  have  been  already  considered  (p.  20).  Functionally,  they  act  as 
ducts  along  which  the  spermatozoids  pass  to  fertilise  the  ovum  ;  and  along 
which  the  ovum,  fertilised  or  non-fertilised  as  the  case  may  be,  is  carried 
to  the  uterine  cavity.  So  far  as  we  know  this  is  all  their  physiological 
function,  unless  we  hold  with  Tait  that  they  play  some  important  though 
as  yet  undefined  part  in  menstruation.  Pathologically,  the  Fallopian  tubes 

• 

are  important  from  the  occurrence  of  extra-uterine  pregnancy  in  them  and 
their  occasional  dilatation  with  pus  or  blood.  From  the  fact  that  they 
open  on  the  one  hand  into  the  uterus,  and  on  the  other  hand  into  the 
peritoneum,  very  serious  results  may  follow  from  fluid  accumulations  in 
them,  from  spreading  gonorrhoea,  or  from  injections  into  the  uterus. 

Can  the  normal  Fallopian  tube  be  palpated  in  the  Bimanual  ?  The  student 
will  probably  have  already  noted  that,  in  considering  the  bimanual  (p.  101), 
we  did  not  name  the  Fallopian  tubes  as  structures  whose  form  and  limits 
he  was  expected  to  define.  In  a  very  favourable  case,  the  conjoined  man- 


183  MANUAL    OF    GYNECOLOGT. 

ipulation  may  define  them  at  their  uterine  origin — more  especially  if  the 
rectal  examination  be  made  and  the  uterus  be  well  drawn  down  with  the 
.  volsella.  Noeggerath  has  pointed  out  that  they  may  be  defined  in  those 
cases  where  the  finger  is  passed  along  the  urethra  to  explore  the  interior 
of  the  bladder,  an  operative  procedure  to  be  described  afterwards.  Prac- 
tically the  Fallopian  tubes,  unless  much  dilated,  are  not  palpable  to  ordin- 
ary examination. 

Catheterisatiqn  of  the  Tubes. — In  certain  undoubted  cases  the  uterine 
sound  has  been  passed  along  the  Fallopian  tube,  while  in  others  the 
supposed  sounding  of  the  tube  has  been  really  the  perforation  of  the 
uterine  wall.  It  is  impracticable  to  sound  the  normal  Fallopian  tubes  to 
any  effect ;  and  the  procedure,  or  rather  the  attempt,  is  by  no  means 
devoid  of  danger. 

We  now  take  up  their  pathological  conditions  under  the  heads  of — 
Abnormalities, 

• 

Stricture  and  Occlusion, 

Patent  Condition  of  the  Tubes, 

Inflammatory  Conditions  of  the  Tubes, 

Hydrops  Tubse, 

Pyosalpinx  and  Hsematosalpinx, 

New  Formations. 

Extra-uterine  Foetation  (to  be  considered  under  Section  IX.). 

ABNORMALITIES. 

These  are  of  little  practical  interest.  The  chief  one  is  an  accessory 
fimbriated  end. 

STRICTURE   OF   THE   TUBES. 

The  tube  may  have  a  congenital  stricture  ;  or  may  become  closed  at 
the  uterine  or  the  fimbriated  end  or  in  the  middle.  When  stricture  oc- 
curs at  the  uterine  end,  it  is  caused  by  implantation  of  the  placenta  there 
or  by  endometritis  with  adhesion.  In  the  middle,  small  tumours  or 
adhesions  may  cause  stricture — in  the  latter  case  usually  partial.  At  the 
fimbriated  end,  the  occlusion  is  due  to  a  catarrh  of  the  tubes  which  has 
spread  to  the  peritoneum  and  set  up  adhesive  peritonitis. 

These  strictures  are  of  importance  in  relation  to  sterility  and  fluid 
accumulations,  but  cannot  be  diagnosed  during  life. 


AFFECTIONS    OF   THE    FALLOPIAN    TUBES    AND    OVARIES.       189 
PATENT    CONDITION   OF   THE   TUBES. 

By  this  is  meant  undue  dilatability.  It  is  of  great  importance  in  re- 
lation to  uterine  injections.  Even  in  careful  injection  of  the  uterine 
cavity,  post-partum  or  otherwise,  fatal  results  have  followed  from  the  fluid 
passing  along  the  tube  into  the  peritoneal  cavity.  "  Forcible  uterine  in- 
jections on  the  cadaver,  with  the  cervix  entirely  filled  up  by  the  syringe, 
almost  always  sent  fluid  along  the  tubes  into  the  peritoneal  cavity.  Less 
forcible  injections  under  like  conditions  sent  the  fluid  along  a  less  distance 
(2-3  mm.),  and  often  sent  it  into  the  veins ;  while  gentle  injections  with  a 
tube  not  filling  the  cervical  canal  sant  fluid  neither  into  the  tubes  nor 


Fig.  124. 

Hydrops  tnbae :  a,  uterus  with  cervix  laid  open  in  front ;  66,  Fallopian  tubes ;  er,  hydrops ;  d ,  part  of  an 
inflammatory  adhesion  ;  ee,  ovaries  (Hennig). 

veins."  Bandl,  from  whom  the  above  is  taken,  records  a  case  where  death 
resulted  from  injection  of  an  aborting  uterus  with  perchloride  of  iron, 
although  the  injection-pipe  was  less  in  diameter  than  the  cervix.  The 
death  may  be  immediate  from  shock,  or  some  days  after  from  peritonitis. 
In  uterine  injections  no  more  than  1-4  drops  should  be  used. 


INFLAMMATORY  CONDITIONS  OF  THE  TUBES,  CATARRHAL  SALPINGITIS. 

The  Fallopian  tube  has  three  layers — peritoneal,  muscular,  and  mucous. 
An  inflammatory  condition  of  the  peritoneum  (perisalpingitis)  is  simply 
part  of  ordinary  pelvic  peritonitis,  is  not  diagnosable,  and  is  not  in  itself 
of  any  importance.  The  same  may  be  said  of  mesosalpingitis  (inflamma- 
tion of  the  muscular  coat). 


190  MANUAL    OF    GYNECOLOGY. 

Catarrh  of  the  mucous  membrane  lining  the  Fallopian  tube  (catarrhal 
salpingitis)  is  not  idiopathic,  but  is  secondary  to  endometritis. 

Pathological  Anatomy. — In  acute  catarrh  in  adults  the  tube  contains 
neutral  or  acid  mucus  in  excess,  glandular  cells,  and  ciliated  epithelium. 

Chronic  catarrh  is  more  frequent  than  acute,  and  occurs  in  all  degrees 
from  a  simple  hyperremia  to  the  formation  of  pus.  The  tube  is  often 
dilated  and  may  communicate  with  a  cavity  in  the  ovary. 

As  the  condition  is  not  diagnosable  during  life  no  treatment  can  be 
indicated. 

\ 

HYDROPS    TDRE. 

As  the  result  of  stricture  of  the  tube  and  marked  catarrh,  we  get  the  tube 
distended  with  serum  (hydrops  tubse)  or  pus  (pyosalpinx) . 

Pathological  Anatomy. — The  whole  or  only  a  part  of  the  tube  is 
dilated,  according  to  the  locality  of  the  stricture  (Fig.  124).  There  may 
be  several  strictures  and  thus  several  cysts.  The  tube  distends  and 
atrophies,  so  that  the  mucous  membrane  becomes  thin  and  the  muscular 
coat  disappears.  The  fluid  is  usually  serum  with  cholesterine  and  occa- 
sionally blood. 

It  is  alleged  that  fluid  can  accumulate  in  the  tube  although  the  uterine 
end  is  open  ;  the  fluid,  at  a  certain  stage  of  its  accumulation,  flows  into 
the  uterus  (profluent  dropsy  of  the  tube). 

Physical  Signs. — An  elongated  tortuous  tube  is  found  at  one  side  of 
the  uterus  and  high  up  in  the  pelvis.  Usually  a  small  piece  of  the  undi- 
lated  tube  can  be  felt  between  the  sac  and  the  uterus. 

The  Differential  Diagnosis  must  be  made  from  the  following : — 

(1.)  Inflammatory  conditions  or  blood  extravasation  in  the  broad 

ligament ; 

(2.)  Fallopian  tube  pregnancy  ; 
(3.)  Small  ovarian  cyst ; 
(4.)  Parovarian  cyst ; 

(5.)  Ketention  of  blood  in  maldeveloped  uterus. 

Treatment. — When  adhesions  are  present  we  should  puncture  with 
Matthieu's  aspirator  through  the  lateral  fornix.  When  the  dilated  tubes 
are  free,  or  but  partially  adherent,  they  may  be  removed  by  abdominal 
incision,  as  Lawson  Tait  has  recently  done. 


AFFECTIONS    OF    THE    FALLOPIAN    TUBES    AND    OVAKIES.        191 

PYOSALPINX. 

This  is  acute  or  chronic,  and  consists  in  the  accumulation  of  pus  in 
the  tubes. 

DiarjHo*!*  and  Treatment  is  much  as  in  hydrops  tuba?.  If  the  tube 
burst,  a  fatal  peritonitis  is  set  up  ;  adhesions  may  form  and  perforation 
into  the  vagina  or  rectum  ensue. 

H2EMATOSALPIXX. 

This  is  a  rare  condition  in  which  the  blood  from  the  congested  mucous 
membrane  of  the  tube  is  detained  there  and  dilates  it.  It  is  often  as- 
sociated with  retention  of  menstrual  blood  in  the  uterus  (>•.  Atresia 
Vagina').  lJia//iio,<i.^  is  difficult  ;  Baudl  records  one  case  where  he 
diagnosed  the  condition  as  a  fibroid,  and  Lawson  Tait  one  simulating  an 
ovarian  cyst.  liokitanslcy  indeed  has  said,  "  Die  Gyniikologen  erkennen 
leidcr  diesen  Zustand  zu  spiit "  (Gynecologists  diagnose  this  condition, 
unfortunately,  too  late). 

NEW  FORMATIONS. 

These  we  merely  enumerate.  They  are  connective-tissue  growths, 
lipomata,  primary  tuberculosis,  carcinomata. 

PAROYARIOI. 

We  have  already  described  the  rudimentary  structure  known  as  the 
parovarium.  Sometimes  one  or  more,  usually  one,  of  the  tubules  be- 
comes distended  with  lluid.  This  distention  may  be  very  great  and  con- 
stitutes the  tumour  known  as  parovarian  ;  its  consideration  will  be  best 
deferred  till  we  treat  of  Ovarian  Tumours. 

ROUND  LIGAMENT;  TIVDROCKLE. 


X'llun:  ami  /'«//< 'y/o^/Vf//  Ati/iju/n  >/.  --- Tliis  is  a  rare  malady,  and  may 
exist  as  encysted  fluid  round  the  round  ligament  (extra  peritoneal),  or  in 
the  canal  of  Xuck —  a  process  of  peritoneum  extending  from  llie  internal 
inguinal  ring  into  the  labium  miijus.  It  may  be  closed  at  the  internal 


192  MANUAL    OF    GYNECOLOGY. 

ring,  thus  forming  a  cyst ;  or  it  may  communicate  with  the  peritoneal 
cavity. 

The  fluid  is  serous  in  its  nature  ;  it  may  be  olive  green  in  colour. 
The  authors  have  seen  three  cases — one  extra-peritoneal,  two  intra- 
peritoneal. 

Physical  Signs,  (a. )  Of  encysted  hydrocele  of  the  cord. 

An  oval  translucent  swelling  exists  in  the  inguinal  canal.  It  cannot 
fee  returned  into  the  abdominal  cavity,  has  usually  existed  for  some  time, 
is  not  tender  on  pressure,  and  gives  rise  to  no  symptoms.  It  must  be 
differentiated  from  an  ovary  in  the  inguinal  canal,  and  from  incarcerated 
hernia. 

(b.)  Of  hydrocele  in  the  labium  majus. 

The  labium  majus  is  distended  with  a  fluctuating  tumour,  dull  on 
percussion  and  of  translucent  appearance  ;  usually  the  contents  cannot  be 
returned  into  the  abdominal  cavity.  Aspiration  gives  a  clear  fluid.  It  is 
to  be  diagnosed  from  hernia  in  the  usual  way. 

Treatment. — Aspiration  and  drainage  ;  or  aspiration  and  injection  of 
a  few  drops  of  tincture  of  iodine.  Goodell  recommends  that  when  the 
labial  form  communicates  with  the  abdominal  cavity,  the  internal  ring 
should  first  be  firmly  compressed  and  the  injected  fluid  then  sucked  out. 

BROAD  LIGAMENT. 

Hsematocele  and  inflammatory  conditions  of  the  broad  ligament  have 
been  already  considered.  We  need  only  further  mention  that  we  may 
have  small  cysts,  fibroids  (rare),  phleboliths,  cancer,  and  tuberculosis ; 
the  last  two  are  only  parts  of  the  general  peritoneal  affection. 

TUBO-OVARIAN  CYSTS. 

These  result  from  adhesions  between  the  fimbriated  end  of  the  Fallo- 
pian tube  and  the  ovary  with  degeneration  of  the  corpora  lutea  of  the 
Graafian  follicles  thus  enclosed.  The  contents  may  be  poured  into  the 
uterus  along  the  tube. 


CHAPTER  XVIII. 

MALFORMATIONS  OF  OVAEY;  OVARITIS  AND  PERIOVARITIS; 
DISPLACEMENTS  OF  OVARY— HERNIA ;  PROLAPSUS. 


LITERATURE. 

Barnes— Op.  cit.,  p.  297.  EngKsch—Oesterr.  Med.  Jahrbuch,  1871,  p.  335;  or, 
Sydenham  Year  Book,  1871-72,  p.  293.  f'reund—Vie  Lage  und  Entwickelung 
der  Beckenorgane :  Breslau,  1863.  Herman— Prolapse  of  the  Ovaries:  Med. 
Times  and  Gazette,  October  22,  1881.  Klob— Pathologische  Anatomieder  weib- 
lichen  Sexual  Organe  :  Wien,  1864.  Munde — Prolapse  of  the  Ovaries  :  Am.  Gyn. 
Tr.,  1879,  p.  164.  Ohhausen — Die  Krankheiten  der  Ovarien :  Billroth's  Hand- 
buch,  Stuttgart.  Schroeder—Op.  cit.,  S.  341.  Schultze— Qp.  cit. 

WE  first  take  up  some  preliminary  considerations. 

Palpation  of  Normal  Ovaries. — After  the  student  has  had  practice  in  the 
bimanual,  he  will  probably  meet  with  some  favourable  case  where  he  is 
able  to  feel  the  normal  sized  ovary.  This  is  best  done  as  Schultze  recom- 
mends. To  map  out  the  right  ovary,  use  the  index  and  middle  fingers  of 
the  right  hand  internally  and  the  left  hand  externally  ;  for  the  left  ovary, 
the  left  hand  is  used  internally,  and"  the  right  externally.  The  patient 
should  lie  on  her  back,  with  the  knees  drawn  up  and  the  legs  rotated  out- 
wards. This  rotation  of  the  knees  renders  the  psoas  muscles  tense,  thus 
making  their  inner  edges  (which  Schultze  gives  as  a  guide  to  the  position 
of  the  ovaries)  more  easily  palpable.  Normally,  they  lie  at  about  the  level 
of  the  pelvic  brim,  half-way  between  the  Fallopian  tube  angle  of  the  uterus 
and  the  psoas. 

Another  method  of  palpating  the  ovaries  is  to  draw  down  the  uterus 
with  the  volsella,  and  make  the  examination  with  the  finger  per  rectum. 

MALFORMATIONS   OF   OVARY. 

Absence  of  one  or  both  ovaries,  or  rather  their  very  rudimentary  de- 
velopment, is  generally  only  part  of  maldevelopment»of  the  uterus.     Oc- 
VOL.  I.— 13 


194:  MANUAL    OF    GYNECOLOGY. 

casionally  a  third  ovary  is  present — a  fact  worth  keeping  in  mind  in  rela- 
tion to  Battey's  operation  (Chap.  XIX.). 

OVARITIS   AND   PERIOVARITIS. 

SYNONYMS — Oophoritis  :  Peri-oophoritis. 

NATURE. — An  acute  or  chronic  inflammation  of  the  ovary. 

PATHOLOGICAL   ANATOMY. 

Acute  Ovaritis. — In  this  we  recognize  two  forms  occurring  in  the  two 
subdivisions  of  ovarian  tissue,  the  follicular  or  parenchymatous,  and  the 
interstitial. 

In  the  follicular  form,  the  ovary  is  not  much  enlarged  ;  but  we  find,  on 
microscopical  examination,  the  peripheral  follicles  increased  in  size,  their 
contents  turbid  or  purulent,  and  the  cells  of  the  membrana  granulosa  in  a 
state  of  cloudy  swelling.  Usually  the  surrounding  tissue  participates, 
though  to  a  less  marked  degree,  in  the  inflammatory  changes. 

In  the  interstitial  form,  the  ovary  is  increased  in  size  and  its  connective 
tissue  elements  are  proliferated.  Pus  may  form,  and  often  there  are  small 
apoplexies  (Olshausen). 

Chronic  Ovaritis. — As  the  result  of  this,  we  get  destruction  of  the  folli- 
cles and  a  cirrhotic  condition  of  the  organ.  Occasionally  the  ovary  remains 
distinctly  larger.  Whether  or  not  we  get  a  super-involution  of  the  uterus 
as  the  result  of  severe  and  double  ovaritis,  is  not  as  yet  settled. 

ETIOLOGY. 

The  causes  of  ovaritis  are  the  following  : 

1.  Gonorrhoea,  latent  gonorrhoea  in  the  male  ; 

2.  Instrumental  exploration  of  the  uterus  ; 

3.  Childbirth  and  abortion  ; 

4.  Acute  febrile  diseases  ; 
.    5.  Pelvic  peritonitis. 

Gonorrhoea. — The  ovaries  may  be  inflamed  sympathetically,  just  as  the 
testicles  are  hi  gonorrhoea  of  the  male. 

Instrumental  Exploration. — Sometimes  after  the  passage  of  the  uterine 
sound,  especially  in  difficult  cases,  the  ovary  becomes  tender. 

Childbirth  and  Abortion. — This  is  a  common  cause  of  ovaritis.   Thus,  in 


AFFECTIONS    OF   THE    FALLOPIAN    TUBES    AND    OVARIES.       195 

27  septic  cases  at  Halle,  Olshausen  found  the  ovaries  affected  in  13.  Usu- 
ally both  ovaries  are  implicated. 

Acute  Febrile  Diseases. — Cholera,  the  exanthemata,  septicaemia,  phos- 
phorus and  arsenic  poisoning,  have  ovaritis  as  one  of  their  results. 

Pelvic  Peritonitis. — It  will  readily  be  understood  that  ovaritis  often  oc- 
curs as  part  of  general  pelvic  peritonitis. 

The  follicular  form  usually  occurs  in  febrile  diseases  and  pelvic  peri- 
tonitis ;  the  interstitial  form  is  generally  puerperal. 

SYMPTOMS    AND    PHYSICAL    SIGNS. 

Acute  Ovaritis. — A  case  of  simple  acute  ovaritis  is  not  common.  The 
patient  usually  complains  of  pain  at  the  side  radiating. to  the  back,  and  of 
pain  on  pressure  in  the  iliac  fossae. 

When  the  bimanual  is  made,  the  ovary  or  ovaries  are  more  accessible 
and  are  felt  as  mobile,  tender,  and  somewhat  enlarged  bodies,  often  about 
the  size  of  a  walnut ;  and  pressure  causes  great  pain  of  a  sickening  char- 
acter. Owing  to  adhesions,  the  mobility  may  be  wanting.  The  uterus  is 
felt  distinct  from  them. 

Chronic  Ovaritis. — The  symptoms  and  physical  signs  are  just  as  in  the 
acute  form,  but  much  less  marked  and  with  a  chronic  history.  Menorrha- 
gia  is  often  present.  Sympathetic  pain  is  sometimes  felt  below  the  left 
mamma. 

DIFFERENTIAL    DIAGNOSIS. 

When  the  ovary  is  not  fixed,  there  is  nothing  else  with  which  it  can  be 
confounded. 

PROGRESS    AND    RESULTS. 

We  may  have  resolution  of  the  affection,  adhesion,  suppuration,  and 
abscess.  Sterility  is  a  frequent  result  of  double  ovaritis  ;  hysteria  is  often 
present. 

TREATMENT. 

Acute  Ovaritis. — A  fly-blister  should  be  applied  over  the  appropriate 
iliac  region,  and  the  hot  vaginal  douche  frequently  used.  Bromide  of 
potassium  may  be  given  as  follows  : — 

1£ .  Potassii  Bromidi gr.  xxx.  to  3  i- 

Fiat  pulv. :         tales  xii. 
Sig.  One  powder  at  night. 


196  MANUAL    OF    GYNECOLOGY. 

Chronic  Ovaritis. — The  hot  douche  and  occasional  blisters  are  best. 
The  glycerine  plug  is  of  value. 

A  glycerine  plug  is  made  as  follows :  take  a  square  piece  of  absorbent 
cotton-wool  about  the  size  of  the  palm  of  the  hand  ;  pour  on  its  centre 
about  3  ss.  glycerine  ;  turn  the  corners  over  and  squeeze  the  whole  so  as 
to  saturate  it ;  lastly,  tie  a  piece  of  thread  about  8  inches  long  round  it. 
Pass  Sims'  or  Fergusson's  speculum  and  place  the  plug  in  the  fornix  below 
the  ovary.  It  should  be  left  in  for  18  to  24  hours,  and  then  withdrawn. 

This  plug  reduces  congestion,  owing  to  the  affinity  of  glycerine  for 
water  ;  has  an  antiseptic  action  ;  and,  as  we  shall  afterward  see,  forms  an 
admirable  pessary.  It  sets  up  a  watery  discharge,  so  that  the  patient 
should  be  told  to  wear  a  diaper  on  account  of  this. 

The  following  mixture  is  of  use  : 

IJ  •  Potassii  Bromidi, 

Potassii  lodidi aa  3  ij. 

Inf.  Gentian §  vi. 

Sig.  Tablespoonful  thrice  daily. 

PERIOVARITIS. 

By  this  we  understand  an  inflammatory  affection  of  the  tissues  sur- 
rounding the  ovary,  which  fixes  the  organ.  It  is  a  convenient  clinical 
term  for  local  peritonitic  inflammations  in  the  site  of  one  of  the  ovaries. 
It  is  higher  up  than  the  usual  cellulitic  deposit.  Its  treatment  is  just  as 
in  chronic  ovaritis. 

DISPLACEMENTS   OF   THE   OVARY— HERNIA. 

The  term  Hernia  is  limited  to  those  cases  where  the  ovaries  are  pres- 
ent in  the  inguinal  canals,  in  the  obturator  foramen  (rare),  or  as  part  of 
an  abdominal  hernia.  Percival  Pott's  case,  where  this  first  condition  ex- 
isted and  where  he  excised  both  of  the  displaced  organs,  is  the  classical 
instance  of  this  displacement.  The  usual  form  is  where  they  are  present 
in  the  inguinal  canal. 

ETIOLOGY. 

Ovaries  in  the  inguinal  canal  are  usually  congenital,  having  descended 
along  the  unobliterated  process  of  peritoneum.  In  17  out  of  23  cases, 


AFFECTIONS    OF    THE    FALLOPIAN    TUBES    AND    OVARIES.       197 

Englisch  found  it  to  be  congenital ;  and  in  one-third  of  these,  the  hernia 
was  double. 

DIAGNOSIS   AND    DIFFERENTIAL   DIAGNOSIS. 

An  oval  tumour  of  the  size  of  the  ovary,  tender  on  pressure,  is  found 
in  the  inguinal  canal.  Its  connection  with  the  uterus  may  be  demon- 
strated by  drawing  the  latter  down  with  a  volsella. 

It  requires  to  be  diagnosed  from  an  ordinary  hernia,  and  from  hydro- 
cele  of  the  round  ligament. 

TREATMENT. 

A  protecting  shield  may  be  worn  ;  and  where  very  troublesome,  the 
ovaries  may  be  cut  down  upon  and  removed.  Reduction  is  usually  im- 
possible, owing  to  adhesions. 

PROLAPSUS. 

We  have  already  considered  the  support  of  the  ovary.  Its  attach- 
ments to  the  broad  ligament,  to  its  own  special  ovarian  ligament,  and  to 
the  ovarian  fimbria  of  the  Fallopian  tube,  support  it  directly.  The  infun- 
dibulo-pelvic  ligament  of  the  Fallopian  tube  does  so  indirectly ;  and,  in 
addition,  its  own  specific  gravity  has  an  influence  in  determining  its  level. 
The  ovary  has  its  position  constantly  changing.  As  the  bladder  fills,  it  is 
displaced  backward ;  and  during  pregnancy,  it  is  drawn  upward  out  of 
its  pelvic  position  and  somewhat  enlarged.  The  ovary  is  thus  an  organ 
liable  to  displacement,  of  which  the  most  important  is  the  downward  one 
— known  as  prolapsus  of  the  ovary. 

PATHOLOGICAL   ANATOMY. 

The  ovary  may  lie  lower  than  usual,  in  the  lateral  or  in  the  true  pouch 
of  Douglas ;  the  uterus  may  be  in  its  normal  position,  but  oftener  it  is 
retroverted.  The  ovary  is  usually  enlarged  and  often  fixed  by  periton- 
itic  adhesions. 

Munde  considers  the  varieties  of  prolapsus  as — 
(1.)  Retro-lateral,  in  the  lateral  pouch  of  Douglas  ; 
(2.)  Retro-uterine,  in  the  true  pouch  of  Douglas  ; 
(3.)  Ante-uterine,  in  the  anterior  fornix,  very  rare  ; 
(4.)  In  the  infundibulum  of  an  inverted  uterus.     The  authors  have 
seen  this  last  in  a  case  under  Professor  Simpson's  charge. 


198  MANUAL    OF    GYNECOLOGY. 

ETIOLOGY. 

The  conditions  present  in  the  puerperium  favour  displacement  of  the 
dvary  for  two  reasons  ;  the  normal  ascent  of  the  uterus  during  pregnancy 
may  stretch  the  ovarian  ligament,  and  the  ovary  may  not  return  to  its 
normal  size  after  parturition.  Simple  congestion  of  the  organ  may  cause 
it  to  descend  ;  and  it  is  alleged  that  sudden  jolts  may  also  drive  it  below 
its  normal  site.  It  is  not  quite  certain  whether  the  congestion  is  cause  or 
result.  Probably  it  is  the  cause  ;  but  it  is  also  aggravated  by  the  dis- 
placement. 

SYMPTOMS. 

These  are  radiating  pains,  pain  on  defecation  and  coitus,  a  dragging 
sensation,  reflex  nervous  symptoms  with  general  irritability. 

PHYSICAL    SIGNS. 

Bimanually,  we  feel  in  the  true  or  in  the  lateral  pouch  of  Douglas  a 
small  body  or  bodies,  exquisitely  tender  and  lying  distinct  from  the  uterus. 
By  the  rectal  examination,  the  ovary  is  felt  with  unusual  distinctness. 

TREATMENT. 

Blisters  over  the  iliac  region,  hot  vaginal  douche,  and  bromide  of 
potassium  in  fifteen-grain  doses  thrice  daily.  The  bowels  are  to  be 
opened  by  means  of  saline  purgatives,  such  as  the  Friedrichshall  water  or 
Carlsbad  salts.  The  following  mixture  is  good. 

t> .   Magnesise  Sulphatis 3  vj. 

Quiniae  Sulphatis gr.  xxiv. 

Acidi  Sulph.  dil 3  iij. 

Tincturse  Capsici 3  j. 

Aquam ad  §  vj. 

Sig.  Tablespoonful  thrice  daily. 

This  relieves  the  congestion  by  unloading  the  bowels. 

Often  the  prolapsed  and  non -fixed  organ  becomes,  after  a  week  of  this 
treatment,  distinctly  higher  in  position.  The  glycerine  plug  is  then  of 
the  utmost  value. 

In  the  chronic  stage,  when  the  uterus  is  retroverted  and  not  fixed,  the 
ring  or  the  Albert  Smith  pessary  is  good  (v.  Ketroversion  of  Uterus). 


AFFECTIONS    OF   THE    FALLOPIAN    TUBES    AND    OVARIES.       199 

The  cases  where  the  tender  ovaries  are  fixed  low  down  by  adhesions 
are  exceedingly  difficult  to  treat.  When  the  uterus  is  retroverted  and 
fixed  and  the  ovaries  below  it,  we  get  one  of  the  most  troublesome  cases 
possible.  Palliative  treatment  by  blisters  and  the  hot  douche  is  best ;  if 
the  case  is  not  amenable  to  this  treatment  and  the  patient's  general 


Eg:  125. 

Mund6's  pessary  for  prolapsed  ovary.     The  cut  away  corner  lies  below  the  prolapsed  ovary. 

health  is  suffering,  the  propriety  of  Battey's  operation  should  be  con- 
sidered. 

Prolapse  of  the  ovaries  and  their  fixations  are  centra-indications  to 
treatment  indicated  otherwise — such  as  Sims'  division  of  the  cervix  and 
Emmet's  operation. 

In  some  cases  of  chronic  unilateral  prolapse,  Munde  has  found  the 
pessary  shown  at  Fig.  125  of  value.  It  indicates  the  kind  of  variation  of 
the  form  of  the  instrument  required  in  different  cases — as,  for  example, 
in  double  prolapsus  or  prolapsed  ovary  lying  just  behind  the  cervix. 


CHAPTER  XIX. 

BATTEY'S   OPEEATION. 

LITERATURE. 

The  literature  on  this  operation  is  too  extensive  to  be  given  in  detail  in  a  student's 
manual.  The  best  summaries  of  cases  are  by  Engelmann,  Hegar,  and  Simpson. 
Battey — Battey's  Operation:  Transactions  of  International  Medical  Congress, 
Lond.,  1881.  See  Am.  J.  of  Obst.,  October.  1881,  for  discussion.  Engelmann — 
The  Difficulties  and  Dangers  of  Battey's  Operation :  Am.  Med.  Asso.  Trans. ,  1878 
(date  of  reprint) ;  also  Battey's,  Operation,  3  fatal  cases :  Am.  J.  of  Obst.,  July, 
1878.  Hegar — Die  Castration  der  Frauen,  Volkmann's  Sammlung,  Nos.  136-138. 
Simpson,  A.  Russell — History  of  a  Case  of  Double  Oophorectomy,  or  Battey's 
Operation  :  Br.  Med.  J.,  May  24,  1879.  Sims,  J.  Marion — Remarks  on  Bnttey's 
Operation :  Br.  Med.  Journal,  1877.  For  additional  literature  see  American 
Gynec.  Trans. ,  1879. 

HISTORY   OF   OPERATION. 

THE  real  history  dates  from  August  17,  1872,  when  Dr.  Battey,  of  Eome, 
Georgia,  U.S.A.,  successfully  removed  the  ovaries  of  a  patient  who  suffered 
from  intolerable  dysmenorrhoea.  On  July  27th  of  the  same  year,  Hegar 
of  Freiburg  removed  both  ovaries  in  a  case  of  severe  ovarian  neuralgia : 
the  patient  died  and  Hegar  did  not  publish  an  account  of  the  case.  Blun- 
dell  of  London  (1823),  with  that  rare  medical  insight  and  experimental 
knowledge  which  led  him  to  advocate — if  not  to  practise — what  recent  ob- 
stetric science  has  shown  to  be  the  safest  mode  of  performing  the  Csesarean 
Section,  had  already  thrown  out  the  suggestion  that  the  ovaries  should  be 
removed  in  dysmenorrhoea  and  to  arrest  hemorrhage  in  inverted  uterus. 
To  Battey,  however,  is  due  the  honor  of  independently  conceiving  the  idea, 
and — what  was  more  difficult — of  successfully  carrying  it  into  execution 
and  impressing  the  profession  with  its  importance  and  value  in  special  cases. 

NOMENCLATURE. 

We  have  adopted  the  term  Battey's  Operation,  first  proposed  by  Marion 
Sims,  as  a  convenient  and  useful  one.     Other  terms,  however,  have  been 


AFFECTIONS    OF    THE    FALLOPIAN    TUBES    AND    OVARIES.       201 

proposed.  The  name  "Normal  Ovariotomy"  is  a  misnomer,  inasmuch  as 
the  ovaries  are  not  normal.  "  Spaying,"  a  term  advocated  by  Goodell, 
does  not  recommend  itself  by  its  delicacy.  "  Die  Castration  der  Frauen," 
the  German  name  for  the  operation,  is  open  to  a  similar  objection. 

NATURE    AND   AIMS   OF    OPERATION. 

Battey's  operation  consists  in  the  removal  of  both  ovaries  which, 
although  diseased,  are  not  appreciably  enlarged.  Battey  proposed  it  for 
dysmenorrhcea,  on  the  theory  that  it  would  bring  on  the  menopause  pre- 
maturely. •  This,  however,  does  not  occur  as  an  immediate  result.  More 
recently,  Battey  has  declared  that  he  operates  to  arrest  ovulation. 

rNDICATIONS   FOB   OPERATION   AND   ITS   RESULTS. 

These  are  not  as  yet  strictly  determined ;  i.e.,  so  far  as  our  present 
knowledge  goes,  the  operation  is  indicated  in  certain  conditions  but  as  yet 
we  do  not  know  whether  in  all  of  them  it  produces  the  anticipated  effect. 
They  are  as  follows  : — 

(1.)  Intolerable  dysmenorrhcea  ; 

(2.)  Bleeding  from  fibroid  tumours,  uncontrollable  by  other 

means  ; 

(3.)  Hystero-epilepsy,   convulsions  and  threatened   insanity, 
dependent  on  ovarian  irritation  or  presence  of  ovaries 
with  absence  of  uterus ; 
(4.)  Hydroperitoneum  ; 
(5.)  Prolapsed  and  fixed  ovaries. 

(1.)  Dysmenorrhcea. — In  those  cases  where  the  patient  has  intolerable 
and  prolonged  pain  every  month,  wearing  her  down  and  rendering  habitual 
recourse  to  opiates  necessary,  the  operation  may  be  performed.  It  should 
not  be  forgotten  that  the  results  in  such  cases  are  not  so  brilliant  as  was 
once  expected.  The  menstruation  is  not  at  first  entirely  arrested  by  the 
removal  of  the  ovaries  ;  and,  as  we  have  always  in  such  cases  pelvic  peri- 
tonitis adding  to  the  patient's  misery  and  untouched  by  the  operation,  it 
is  evident  that  we  must  not  expect  too  much  from  it.  Lawson  Tait  believes 
that  the  Fallopian  tubes  must  also  be  removed  ;  but  on  this  point  our  in- 
formation is  scanty. 

(2.)  Bleeding  from  Fibroid  Tumours,  uncontrollable  by  other  Means. — It 
is  in  this  condition,  for  which  Battey's  operation  was  first  advocated  by 


202  MANUAL    OF    GYNECOLOGY. 

Trenholm  and  Hegar,  that  the  most  brilliant  successes  have  been  won. 
Not  only  has  hemorrhage  been  checked,  but  the  tumours  themselves  have 
diminished  in  size  and  even  in  some  cases  disappeared. 

(3.)  In  some  cases  of  hystero-epilepsy,  convulsions,  insanity  and  dancing 
mania,  dependent  on  ovarian  irritation,  the  operation  has  been  performed 
with  but  moderate  success.  Engelmann,  Gilmore,  Kussell  Simpson,  and 
Battey  quote  some  remarkable  cases. 

(4.)  Hydroperitoneum. — Granvill  Bantock  of  London  has  recently  re- 
corded a  case  where  removal  of  both  ovaries  cured  the  hydroperitoneum. 

(5.)  In  cases  of  ovaries  prolapsed  or  fixed  by  adhesions  and  giving  rise 
to  intolerable  pain  in  coitus  or  seriously  affecting  the  patient's  health, 
their  removal  is  called  for. 

At  the  London  International  Congress  the  operation  was  discussed. 
According  to  Battey,  the  mortality  has  been  22  per  cent,  for  incomplete 
operations  and  9£  per  cent,  for  complete  ;  in  the  other  cases,  the  results  as 
to  relief  have  been — 

No.          Per  Cent. 

Cured,         .....  68  75 

Greatly  benefited,  ...  15  17 

Not  benefited,         ....  7  8 

Of  the  incomplete  operations — 

Cured,        .....  3  18 

Greatly  benefited,  ....  7  41 

Not  benefited,        ....  7  41 

The  operators  who  have  operated  most  extensively  have  been  Lawson 
Tait  of  Birmingham,  who  has  excised  the  ovaries  in  70  cases,  and  Savage 
of  Birmingham,  who  has  done  it  in  30  cases. 

Tait  tabulates  his  cases  as  follows. 
Cases  operated  on  for  pains — 

No.  of    Incomplete  T-.     ., 
Cases.     Operations.  L 

Recurrent  Hsematocele,        .            .  1  1  0 

Abscess  of  Ovarj',      ...  2  0  0 

Hydrosalpinx,            ...  2  0  0 

Pyosalpinx,   ....  8  0  0 

Chronic  Ovaritis,      ...  8  2  1 

Cirrhosis  of  Ovaries,              .             .  11  1  0 

32  4  1 


AFFECTIONS    OF    THE    FALLOPIAN    TUBES    A^D    OVARIES.        203 

Cases  operated  on  for  hemorrhage — 

Xo.  of     Incomplete   T, 
Cases.     Operations.   Dcaths' 

Hydrosalpinx,  ...  1  U  0 

Chronic  Ovaritis,        ...  2  U  0 

Small  Cystic  Ovaries,  ..500 

Myoma,  .  .  .  .20  1  5 

34  1  5 

Cases  operated  on  for  Reflex  Symptoms — 

Menstrual  Epilepsy,  ..300 

Deformity,     .  .  .  .  1  0  0 

400 
Total  number  of  cases,  70  5  0 

METHOD  OF  PERFORMING  Till:  OPERATION. 

The  ovaries  may  be  removed  (1)  bij  Uto  rar/iiw.f  method,  or  (2)  />>/ 
abdominal  wtion.  As  the  former  is  the  less  usual  method,  we  shall  de- 
scribe it  but  shortly. 

(1.)  Tli<>.  \\iijinrd  Mclliod. — (jive  chloroform.  Place  the  patient  semi- 
prone  or,  better,  in  the  lithotomy  posture.  Pass  Battey's  speculum,  lay 
hold  of  cervix  uteri  with  a  volsella  and  draw  it  down.  Wash  out  the 
vagina  thoroughly  with  the  douche. 

Now  incise  the  posterior  vaginal  wall,  behind,  the  cervix,  in  the  middle 
line  for  about  an  inch  and  a  half.  Open  into  the  peritoneal  cavity,  pass 
in  the  index  finger  or  long  polypus  forceps  and  hook  down  the  nearer 
ovary  ;  supra-pubic  pressure  i.^  made  by  an  assistant.  Ligature  the 
ovary  at  the  lulus  with  thin  carboli/.ed  silk  threaded  on  a  iixed  needle. 
The  hilus  is  transfixed  mesially  with  the  needle,  the  double  ligature  drawn 
through  and  cut.  one  thread  is  tied  round  the  one  half  of  the  base  and  the 
other  round  the  other  half  :  the  ovary  is  then  cut  off  and  the  ligature  cut 
short.  The  other  ovarv  is  treated  in  the  same  way  ;  we  make  certain  that 
there  is  not  a  third  ovary,  which  would  likewise  remiire  to  be  ligatured. 
Batty  passes  a  temporarv  ligature  round  the  base  of  the  ovary  and  then 
uses  the  ccraseur.  Lastly,  pass  in  a  drainage-tube,  stitch  the  wound 
(Bat ley  leaves  it  unstitched),  and  irrigate  twice  daily  witli  weak  carbolic 
solution  (1  11)0).  After-treatment  as  in  ovariotomy  (  r.  Chap.  XXIT  . 

This  method  is  <rood  when  the  ovaries  are  low  down.      It  is  sometimes 


204  MANUAL    OF    GYNECOLOGY. 

difficult  to  make  out  the  ovary,  and  even  impossible  to  remove  it.  In  one 
case  Battey  had  to  dig  out  portions  with  his  finger-nail ;  all  was  not  re- 
moved and  the  patient  conceived  some  time  afterwards. 

(2.)  Abdominal  Section. — The  instruments  needed  are  the  following  : — 

Spray ; 

Carbolic  lotion  ; 
Sponges  (a  definite  number) ; 
Ordinary  knives ; 
Probe-pointed  bistoury ; 
Spatulse ; 

Dissecting  and  dressing  forceps  ; 
Tenacula,  blunt  hooks ; 

Pean's  artery  forceps,  a  definite  number  (20)  of  pairs ; 
Needles  on  fixed  handles  ; 
Catgut  for  bleeding  vessels  ; 

Long  straight  needles,  threaded  two  on  each  suture  of  silk- 
worm gut ; 

Needle-holder,  with  small  needles  on  horse-hair  sutures  ; 
Thin  carbolized  silk  for  ligaturing  ovary ; 
Drainage-tubes  (glass) ; 
Carbolic  gauze,  mackintosh,  and  flannel  bandages. 

The  spray  should  be  placed  eight  or  nine  feet  from  the  patient.  It  is 
at  present  an  open  question  whether  the  spray  should  play  on  the  wound 
or  merely  into  the  air  of  the  room.  The  instruments  to  be  used  are 
placed  in  a  porcelain  tray  containing  carbolic  acid  1-40.  The  sponges 
are  wrung  out  in  1-60  solution  ;  when  the  peritoneal  cavity  is  opened, 
the  solution  (1-60)  used  for  the  sponges  must  be  warm. 

The  patient  is  placed  in  the  dorsal  posture  and  chloroformed ;  the 
skin  is  shaved  clean,  and  washed  with  turpentine  and  soap  and  then  with 
1-20  carbolic  lotion. 

An  incision,  four  inches  long  and  ending  a  little  above  the  mons  vene- 
ris,  is  made  in  the  middle  line.  The  knife  passes  in  succession  through 
the  following  structures — skin,  fat,  linea  alba,  fascia  transversalis  and 
peritoneum.  Bleeding  is  to  be  arrested  by  Pean's  forceps  left  on  for  a 
time,  or  by  catgut  ligature. 

Great  care  must  be  taken  to  recognize  the  peritoneum.  It  should  be 
lifted  up  with  a  tenaculum  and  an  opening  cautiously  made  with  a  knife 


AFFECTIONS    OF   THE    FALLOPIAN   TUBES    AND    OVARIES.       205 

or  scissors.  Remember  that  the  small  intestines  lie  just  behind  and  may 
be  easily  cut  into.  This  accident,  indeed,  has  occurred  to  such  a  distin- 
guished operator  as  Spencer  Wells  ;  when  it  occurs,  the  aperture  should 
be  stitched  up  with  fine  catgut.  When  once  an  opening  has  been  made 
through  the  peritoneum,  it  can  be  readily  enlarged  to  the  size  of  the 
original  incision  by  means  of  a  probe-pointed  bistoury  guided  on  the 
finger. 

The  fingers  are  now  passed  in,  the  fundus  uteri  is  touched  ;  and  then 
the  fingers,  carried  along  the  Fallopian  tube,  will  recognize  the  ovary 
usually  lying  behind  it.  It  should  be  lifted  up  if  possible  to  the  incision, 
and  ligatured  with  thin  carbolized  silk,  as  described  under  the  vaginal 
method  ;  the  ligatures  are  cut  short  and  each  side  of  the  pedicle  held 
with  Pean's  forceps.  (Marion  Sims  recommends  his  uterine  repositor  as 
an  aid  to  the  elevation  of  the  ovaries.  This  elevation,  however,  can  be 
more  easily  managed  by  introducing  the  two  fingers  or  whole  hand  into 
the  vagina,  and  elevating  all  in  front  of  the  posterior  vaginal  wall.) 

The  ovary  is  then  cut  away  with  the  knife  at  a  point  about  half  an  inch 
clear  of  the  ligature.  The  other  ovary  is  treated  in  the  same  way.  We 
hold  the  pedicle  for  a  time  in  the  Pean's  forceps,  before  dropping  it  back, 
to  see  that  there  is  no  bleeding.  The  peritoneal  cavity  is  now  to  be  thor- 
oughly and  carefully  cleaned  with  sponges  well  wrung  out  of  the  warm 
carbolic  solution  (vide  Chapter  XXII.). 

The  abdominal  incision  is  now  closed  ;  to  prevent  blood  from  passing 
down  while  this  is  being  done,  a  large  flat  sponge,  also  well  wrung  out,  is 
placed  in  the  peritoneal  cavity  just  below  the  incision.  Silkworm-gut  is 
most  suitable  for  the  deep  sutures  in  the  abdominal  incision.  Straight 
needles  are  threaded  one  on  each  end  of  the  silkworm-gut  suture ;  the 
needles  are  passed,  first  the  one  and  then  the  other,  from  the  peritoneal 
aspect  towards  the  skin.  All  the  sutures  are  passed  before  any  one  of 
them  is  ligatured,  and  the  ends  drawn  together  to  judge  if  there  be  suffi- 
cient to  close  the  wound.  The  sponge  placed  below  the  incision  is  now 
removed  before  the  sutures  are  tied.  All  the  sponges  and  forceps  must  now 
be  counted.  Superficial  stitches  of  horse-hair  are  passed  to  adapt  the 
edges  of  the  skin  between  the  deep  sutures.  If  the  operation  has  been 
an  easy  one,  no  drainage  is  needed. 

The  whole  operation  is  by  no  means  an  easy  one.  The  skin  incision 
is  more  difficult  than  in  ovariotomy,  for  there  is  always  a  risk  of  wound- 
ing intestine.  In  some  cases,  Hegar  has  made  a  lateral  incision.  Some- 


206  MANUAL    OF    GYNECOLOGY. 

times,  especially  in  cases  of  fibroids,  it  is  exceedingly  difficult  to  get  at 
the  ovaries.  Engelmann  has  more  particularly  directed  attention  to  this 
point.  In  one  of  his  cases  he  says:  "The  ovaries  were  so  deeply  im- 
bedded within  the  folds  of  the  broad  ligament,  and  with  them  so  firmly 
tied  down  to  the  sides  and  floor  of  the  pelvis  that  it  was  impossible  to 
move  them.  With  the  greatest  difficulty  several  unsatisfactory  ligatures 
were  placed  about  the  left  ovary  ;  but  it  was  useless  even  to  attempt  to 
tie  the  right,  so  intimately  was  it  blended  with  the  broad  ligament,  and 
so  immovably  adherent  to  the  pelvic  walls.  ...  I  enlarged  the  inci- 
sion to  two  inches  above  the  navel,  removed  the  intestine  from  the  pelvic 
cavity  and  then  succeeded  in  enclosing  the  entire  mass  in  the  ligature, 
and  removing  the  ovaries  complete."  Kaltenbach  in  one  case  ruptured 
the  Fallopian  tube  dilated  with  pus  ;  the  patient  died  of  septic  peritonitis. 
Freund,  Martin,  Sims,  and  Battey  have  also  recorded  difficult  cases. 

GENERAL   CONCLUSIONS. 

This  operation  is  as  yet  on  its  trial.  Gynecologists  have  not  yet  set- 
tled the  exact  indications  for  it,  nor  the  question  as  to  whether  it  is  always 
worth  the  risk. 

The  mortality  is  high;  up  to  1879  it  was  37.1  per  cent.  (A.  R. 
Simpson). 

Part  of  this  is,  of  course,  due  to  the  worn-out  state  of  many  of  the 
cases  operated  on  and  to  the  extensive  adhesions  present.  Probably  the 
mortality  will  diminish,  although  it  must  be  kept  in  mind  that  operators 
have  had  the  benefit  of  the  previous  advice  and  experience  of  ovarioto- 
mists  as  to  its  results.  We  have  already  seen  that  its  most  brilliant  suc- 
cesses have  been  got  in  fibroids  ;  its  success  in  other  cases  has  been 
moderate.  When  many  adhesions  exist,  it  is  probably  better  not  to 
attempt  it. 

Some  interesting  physiological  points  have  been  brought  out  by  it ; 
removal  of  the  ovaries  does  not  bring  on  the  menopause,  sexual  appetite 
is  not  diminished,  and  no  womanly  attributes  are  in  any  way  removed. 
The  outcry  that  it  unsexes  a  woman  is  absurd.  The  ovaries  removed  were 
probably  useless  for  procreation  ;  and  when  their  presence  is  causing 
serious  bodily  illness,  they  are  better  removed. 


CHAPTER  XX. 
PATHOLOGY  OF  OVARIAN  TUMOURS. 

LITERATURE. 

Barnes—  Op.  cit.,  p.  322.  De  Sinety — (v.  Malaesez).  Doran — (t>.  Harris).  Drysdale 
On  the  Ovarian  Cell  found  in  Ovarian  Fluid  :  Trans.  Americ.  Med.  Asso.  (1873,  date 
of  reprint).  Foulis— Cancer  of  the  Ovary:  Ed.  Med.  Jour.,  1875,  p.  838.  The 
Diagnosis  of  Malignant  Ovarian  Tumours,  and  Malignant  Peritonitis  :  Brit.  Med. 
Jour.,  1878,  pp.  91  and  658.  Fox,  Wilson—On  the  Origin,  Structure,  and  Mode 
of  Development  of  the  Cystic  Tumours  of  the  Ovary:  Med.  Chir.  Tr.,  Vol. 
XLVII.,  p.  227.  Harris  and  Doran — The  Ovary  in  Incipient  Cystic  Disease: 
Jour,  of  Anat.  and  Physiol.,  Vol.  XV.,  Pt.  IV.,  July,  1881.  Malassez  et  De  Sinety 
— Sur  la  Structure,  1'Origine  et  le  Developement  des  Kystes  de  1'Ovaire  :  Archiv. 
de  Physiologic  Normale  et  Pathologique,  Vol.  V.,  1878.  p.  343.  Noeggerath — Tho 
Diseases  of  Blood-vessels  of  the  Ovary  in  Relation  to  the  Genesis  of  Ovarian 
Cysts:  Am.  Jour,  of  Obst.,  Vol.  XIII.,  1880.  Olshausen—Op.  cit.  Patenko— 
Ueber  die  Entwickelung  der  Corpora  Fibrosa  in  Ovarien  :  Virchow's  Archiv.,  Bd. 
84,  1881.  llindfleisch — Pathological  Histology,  New  Sydenham  Society  Trans- 
lation, 1873,  p.  171.  Sehroeder — Op.  cit.,  S.  355.  Slavjansky — Zur  normalen  und 
pathologischen  Histologie  des  Graaf'schen  Blaschens  des  Menschen :  Virchow's 
Archiv.,  Bd.  51,  1870.  Waldeyer — Die  Eierstockscystome  :  Archiv.  f.  Gynak., 
Bd.  1,  S.  252.  Wells,  T.  £.— Diseases  of  the  Ovaries:  Churchill,  London,  1872. 
Williams — Ovarian  Tumours  :  Reynolds'  System  of  Medicine,  Vol.  V.  Olshausen, 
Sehroeder  and  Williams  give  the  literature  well.  They  should  be  consulted  for 
full  references  if  necessary. 

UNDER  this  head  we  take  up — 

1.  The  mode  of  origin  of  ovarian  cysts  ; 

2.  Varieties  of  ovarian  tumours,  their  naked  eye  and  microscopic 

anatomy  ; 

3.  The  nature  of  ovarian  fluids  and  of  parovarian  fluid ; 

4.  Solid  ovarian  tumours  ;  malignant  tumours  and  the  nature  of  the 

ascitic  fluid  associated  with  them. 


208  MANUAL    OF    GYNECOLOGY. 

THE   MODE   OF   ORIGIN    OF    OVARIAN    CYSTS. 

Our  knowledge  of  the  pathological  anatomy  of  the  ovary  depends  on 
our  information  as  to  its  development,  its  anatomical  structure,  and  the 
physiological  changes  it  undergoes.  On  each  of  these  we  must  make  some 
preliminary  remarks. 

(1.)  As  to  its  development.  We  have  already  seen  that  the  actively 
growing  connective  tissue  of  the  ovary  encloses  the  germ  epithelium  ;  that 
certain  of  the  germ  epithelial  cells  thus  enclosed  develop  into  ova  ;  while 
the  connective  tissue  itself,  according  to  Foulis,  forms  the  membrana 
granulosa  (u.  Plate  VII.,  Fig.  F.).  The  germ  epithelium  thus  enclosed 
gave  rise  to  the  idea  that  the  developing  ovary  was  a  tubular  organ  ;  and 
to  the  epithelium  thus  enclosed  (or  rather,  according  to  Pfliiger,  the  epithe- 
lium penetrating  into  the  ovarian  stroma)  was  given  the  name  of  Pfliiger's 
ducts. 

A  section  of  a  developed  ovary  shows  cellular  structures,  which  (accord- 
ing to  Waldeyer)  are  some  of  Pfluger's  ducts  that  have  not  developed  as 
they  should  have  done  into  Graafian  follicles.  Waldeyer,  therefore,  regards 
Pfluger's  ducts  as  seats  of  origin  of  ovarian  cysts  (Fig.  126). 


Fig.  126. 

Cellular  bodies  alleged  by  Waldeyer  to  be  enclosed  germ  epithelium  which  has  not  developed  into  normal 
Graafian  follicles.     He  believes  these  to  be  one  source  of  ovariali  tumours  (Noeggerath). 

(2.)  The  peculiarities  of  the  anatomical  structure  are  due  to  the  Graafian 
follicles  and  certain  cellular  structures  whose  exact  nature  is  as  yet  debated. 
Of  the  30,000  Graafian  follicles  contained  in  each  ovary,  only  an  insignifi- 
cant number  develop  and  rupture  at  each  menstrual  period.  Many  of  the 
rest  atrophy,  forming  the  corpora  fibrosa  which  are  seen  on  section  as 
fibrous  points  and  contain  no  vessels ;  it  is  alleged  that  these  corpora 
fibrosa  may  originate  also  from  ripe  follicles  or  from  follicles  where  there 
has  been  hemorrhage. 

The  vessels  around  the  follicles  sometimes  degenerate.  The  cellular 
structures  shown  at  Fig.  127  are,  according  to  Noeggerath,  diseased  blood- 
vessels. 


AFFECTIONS    OF   THE    FALLOPIAN   TUBES    AND    OVARIES.       209 

Its  Physiology. — When  we  consider  that  at  each  menstrual  period  a 
Graafian  follicle  distends  and  then  ruptures,  we  are  led  to  expect  what 
really  does  sometimes  occur,  viz.,  that  the  follicle  may  not  rupture  but 
merely  distend  to  form  a  pathological  cyst.  When  pregnancy  occurs,  the 
ruptured  follicle  has  its  large  corpus  luteum  filling  it ;  and  in  this  also  we 
may  have  pathological  development. 


Fig.  127. 

Cellular  bodies  which  Noeggerath  believes  to  be  diseased  blood-vessels  and  not  germ  epithelium,  as  Wai- 
deyer  asserts  (Noeggerath). 

From  these  preliminary  considerations  we  see  that  the  alleged  sources 
for  the  origin  of  ovarian  cysts  are  the  following  : — 

(a.)  Distention  and  coalescence  of  Graafian  follicles  ; 
(b. )  Degeneration  of  true  corpora  lutea  ; 

(c.)  Degeneration  of  undeveloped  Graafian  follicles,  colloid  de- 
generation of  the  ovarian  stroma ; 
(d. )  Degeneration  of  blood-vessels  ; 

(e.)  Pathological  development  of  enclosed  germ  epithelium,  so- 
called  Pflliger's  ducts ; 

(/.)  Certain  epithelial  tubes  running  into  the  ovary  ; 
(g.)  Malignant  development  of  connective  tissue  of  ovary. 
The  student  should  clearly  note  that  these  are  the  theoretical  sources  of 
ovarian  cystic  development,  but  that  (as  we  shall  presently  see)  some  are 
disputed. 

(a.)  Distention  and  Coalescence  of  Graafian  Follicles. — There  can  be  no 
doubt  that  small  cysts  may  so  originate.  The  proof  of  this  is  positive,  as 
Rokitansky  found  ova  in  cysts  about  the  size  of  a  bean.  Wilson  Fox  has 
attempted  to  show,  in  his  well-known  paper,  that  all  the  varieties  of  cystic 
tumours  may  be  formed  in  this  way. 

(b.)  Degeneration  of  true  Corpora  Lutea. — This  has  been  noted  in  some 
cases. 

(c.)  Degeneration  of  undeveloped  Graafian  Follicles. — This  is  probably  an 
important  source.  (For  details  see  Han-is  and  Doran's  article,  and  also 

Slavjansky's  and  Patenko's  papers  for  normal  and  abnormal  involution.) 
VOL.  I.— 14 


210 


MANUAL    OF   GYNECOLOGY. 


(d,  e,  and  /.)  Degeneration  of  Blood-vessels  ;  Degeneration  ofPfliiger's 
Ducts  ;  Epithelial  Tubes  running  into  the  Ovary. — Noeggerath  of  New  York 
first  pointed  out  that  diseased  blood-vessels  might  form  a  source  of  ovarian 
cysts ;  and,  more  recently,  Harris  and  Doran  have  confirmed  his  views. 
According  to  Noeggerath,  we  have  disease  of  the  intima  of  the  vessel,  loss 
of  its  endothelium,  and  percolation  of  the  contents  of  the  vessel  into  the 
intima.  Migrating  cells  accumulate  in  the  interstices  of  the  intima  and 
break  it  up.  The  large  granular  nucleated  cells  found  in  ovarian  cysts  are, 


Fig.  138. 

Section  of  ovary  showing  an  epithelial  tube  (at  the  shaded  part  of  the  section).  Lower  down  are  seen 
spaces  of  varying  size,  and  lined  with  a  single  layer  of  epithelium  ;  these  cysts  are  developed  from  the 
epithelial  tubes.  The  connective  tissue  basis  is  shown  only  at  the  shaded  part  of  section  (De  Sin6ty). 

according  to  him,  these  lymph  corpuscles.  Noeggerath  considers  that  the 
cellular  structures,  which  other  observers  hold  to  be  Pfliiger's  ducts,  are 
diseased  vessels. 

Waldeyer  considers  that  ovarian  tumours  are  developed  from  the 
processes  of  epithelium  known  as  Pfluger's  ducts  ;  they  arise,  therefore, 
from  the  same  source  as  the  Graafian  follicles. 

De  SinSty  and  Malassez  first  described  certain  epithelial  tubes  from 
which  ovarian  tumours  develop  ;  these  are  not  true  Pfliiger's  ducts,  but 


PLATE  YL 


AFFECTIONS    OF    THE    FAXLOPIAN   TUBES    AXD    OVARIES.       211 

differ  from  them  in  being  hollow  and  having  no  ovum.  They  consider 
them  as  Pfliiger's  ducts  which  have  taken  on  a  low  type  of  development 
(Fig.  128). 

The  student  will  therefore  see  that  the  cellular  structures  found  on 
section  of  ovaries,  although  considered  by  all  as  a  source  of  origin  for 
ovarian  cysts,  have  their  nature  disputed.  Noeggerath  believes  them  to  bo 
diseased  blood-vessels  ;  Waldeyer,  Spiegelberg,  and  Schroeder  consider 
them  to  be  Pfliiger's  ducts  ;  De  Siut'ty  and  Malassez  hold  that  they  are 
Pfliiger's  ducts  degraded  in  development. 

(g.)  Malignant  Development  of  Connective  Tissue  of  Ovary. — In  malignant 
disease  of  the  ovary  ascitic  fluid  is  often  formed  in  which  are  characteristic 
cells,  first  described  by  Dr.  J.  Foulis  of  Edinburgh.  Plates  VI.  and  VII. 
show  these.  They  will  be  considered  under  the  aseitic  fluid  associated 
with  malignant  tumours.  Foulis'  developmental  work  on  the  ovary  lias 
valuable  bearings  on  its  pathology. 

At  present  more  light  is  needed  in  ovarian  pathology,  as  can  i-eadily  be 
seen  from  the  heterogeneous  facts  as  yet  at  our  disposal. 

VARIETIES  OF  OVARIAN  TUMOURS  ;    TUEIU    NAKED-EYE  AND  MICROSCOPIC  ANATOMY. 

(1.)   Hydrops  folliculorum. 
(2.)  Cystoma  ovarii — 

a.  Cystoma  ovarii  proliferum  glandulare. 

b.  Cystoma  ovarii  proliferum  papillare. 

(This  is  Waldeyer's  classification.     Piindfloisch  speaks 
of  a  papillary  form,  a  form  caused  by  colloid  de- 
generation of  the  ovarian  stroma  (Figs-  1-!',  130), 
and  a  form  with  cysto-colloid  degeneration. ) 
(3.)  Dermoid  cysts. 
(4.)  Cystoma  malignum. 

Xakcd-cijcd  Anatomy. — We  have  the  cysts  and  their  pedicle.  The  cysts 
are  always  multiple  ;  and  the  pedicle  is  usually  made  up  of  ovarian  liga- 
ment. Fallopian  tube,  and  broad  ligament.  lk>th  cysts  and  pedicle  are 
covered  with  peritoneum.  On  section  of  the  eysloid  lumour  many  cysts 
are  found  with  papillary  projections  and  inter-communications.  Die 
p:ipill;e  may  coalesce  and  form  retention  or  daughter-cysts.  ^Micro- 
scopically we  have  already  noted  that  in  cases  of  hydrops  folliculorum, 
where  the  si/e  is  that  of  a  bean,  the  ovum  has  been  found. 


212 


MANUAL    OF    GYNECOLOGY. 


Microscopic  Anatomy. — The  wall  of  the  cysts  is  made  up  of  stratified 
connective  tissue  lined  by  columnar  epithelium.  In  the  glandular  form 
(cystoma  ovarii  proliferum  glandulare),  the  epithelium  grows  more  out- 
wards and  forms  occluded  follicles  in  the  cyst- wall ;  in  these  again  other 


Fig.  129. 

Section  through  cyst-wall,  showing  papillae  covered  with  columnar  epithelium  and  sub-epithelial  layer 
of  connective  tissue  (Rindfleisch)  200/1. 

follicles  may  develop.  In  the  papillary  form  (cystoma  ovarii  proliferum 
papillare),  the  connective  tissue  of  the  cyst- wall  sprouts  out,  pushing  the 
lining  of  the  cyst  before  it ;  these  papillae  are  covered  with  the  columnar 
epithelium  of  the  cyst. 

Dermoid  cysts  are  due  to  abnormal  inclusion  of  the  epiblast,  i.e.,  are 
developmental  in  their  origin.     They  have  an  outer  fibrous  coat  and  an 


Fig.  130. 
Colloid  degeneration  of  ovarian  stroma  (Rindfleisch). 

inner  one  composed  of  true  skin.     They  may  contain  hair,  teeth,  bone, 
striped  muscle,  nervous  matter,  cholesterine,  and  sebaceous  matter. 

The  cystoma  malignum  is  a  cystic  tumour  which  has  undergone  malig- 
nant degeneration.  It  is  noteworthy  that  malignant  disease  often  devel- 
ops after  the  removal  of  an  apparently  simple  tumour. 


AFFECTIONS    OF    THE    FALLOPIAN   TUBES    AND    OVAKIES.       213 
THE   NATURE   OF   OVARIAN   FLUIDS    AND    OF   PAROVARIAN    FLUID. 

Ovarian  fluid  varies  much  in  consistence  and  color.  It  is  usually 
viscid,  and  may  be  so  thick  as  to  be  almost  gelatinous.  Its  color  is  yel- 
lowish or  greenish ;  and  the  specific  gravity,  when  of  the  more  fluid  con- 
sistence, varies  from  1010  to  1020.  Chemically,  the  fluid  is  complex. 
Eichwald's  results  are  those  usually  given. 

"  According  to  Eichwald  the  fluid  contents  of  the  cysts  may  be  divided 
into  two  distinct  classes  of  elements.  The  elements  of  the  first  class  can 
always  be  distinguished  from  those  of  the  second.  On  the  other  hand, 
the  individual  members  of  one  class  can  only  be  separated  from  each  other 
when  one  or  more  of  the  intermediate  members  are  wanting. 

"  The  two  groups  consist  of  the  mucous  matters  and  the  albuminous 
matters.  In  the  contents  of  large  (old)  colloid  cysts  the  elements  of  the 
second  class  are  apt  to  predominate,  just  as  the  elements  of  the  mucous 
class  do  in  the  contents  of  the  younger  cysts. 

"  The  first  group  is  made  up  of  the  mucous  elements,  which  are  found 
to  be  variously  modified.  These  are  formed  from  the  substance  of  the  col- 
loid bodies,  and  from  the  transformed  parenchyma  of  the  cells.  From  this 
mucine  is  formed,  which,  while  not  soluble  in  water,  is  found  in  the  cysts 
in  a  hydrated  condition.  By  a  series  of  intermediate  changes  the  mucine 
becomes  gradually  converted  into  the  muco-peptone,  which  is  very  readily 
soluble  in  water,  for  mucine  by  degrees  assumes  the  property  of  dis- 
solving in  water,  and  loses  its  peculiarity  of  being  precipitated  by  acids. 
This  substance,  which,  as  we  have  seen,  is  produced  by  mucine  changing 
into  muco-peptone,  and  is  therefore  a  sort  of  modified  mucine,  is  the  so- 
called  colloid  substance.  This  colloid  degeneration  is  therefore  nothing 
else  than  a  mucous  metamorphosis.  The  mucine  group  consists,  there- 
fore of : — 

"  1.  Substance  of  the  colloid  corpuscles.  Only  soluble  in  diluted  alco- 
hol ;  perfectly  precipitated  by  acetic  acid. 

"  2.  Mucine.  Also  soluble  in  alkaline  earths,  and  becomes  hydrated 
in  water  ;  perfectly  precipitated  by  acetic  acid. 

"  3.  Colloid  substance.  Slightly  soluble  in  cold,  but  more  soluble  in 
hot  water.  Becomes  turbid  on  the  addition  of  acetic  acid,  but  does  not 
form  a  perfect  coagulum. 

"  4.  Muco-peptone.  Very  easily  soluble  in  water  ;  not  precipitated  by 
acetic  acid. 


214  MANUAL    OF    GYKECOLOGY. 

"  The  other  class  is  the  albuminous.  The  albumen  is  found  in  colloid 
ovarian  cysts,  under  two  forms,  as  free  albumen  and  as  albuminate  of 
soda.  The  former  coagulates  by  simply  boiling ;  the  latter  only  on  the 
addition  of  an  acid.  The  former,  the  free  albumen,  is  always  changed  in 
colloid  tumours  into  albumino-peptone,  while  the  albuminate  of  soda  re- 
mains unaltered.  This  change  takes  place  very  gradually.  First,  the 
property  of  coagulating  on  being  heated  is  lost— it  becomes  paralbumen  ; 
then  it  loses  by  degrees  the  property  of  being  precipitated  by  the  mineral 
acids,  and  becomes  a  metalbumen.  Paralbumen  and  metalbumen  are, 
however,  not  fixed  bodies,  but  their  peculiarity  consists  in  their  gradual 
change  from  free  albumen  to  peptone. 

"  The  albuminous  group  consists  of : — 

"  1.  Albumen  (fibrine) ; 

"  2.  Paralbumen ; 

"3.  Metalbumen; 

"  4.  Albumino-peptone  (fibro-peptone). 

"The  peculiarities  of  the  several  component  parts  are  the  same  as 
those  of  the  components  of  the  mucine  class.  They  are  distinguished 
from  the  mucine  class  by  the  fact  that  they  contain  sulphur,  and  by  their 
being  precipitated  by  tannin  and  the  neutral  metallic  salts.  Since  albu- 
men gradually  changes  into  peptone,  a  process  takes  place  exactly  like 
that  of  digestion. 

"  On  boiling,  the  contents  of  the  cysts  will  be  found  to  vary  according 
to  the  amount  of  free  albumen  present.  The  fluid  is  perfectly  clear  if  all 
the  free  albumen  remains  unchanged,  but  on  the  addition  of  acid  it  always 
becomes  turbid,  inasmuch  as  it  then  invariably  contains  the  albuminate  of 
soda." — (From  Schroeder.) 

Ovarian  fluid  does  not  give  a  flocculent  precipitate  as  ascitic  fluid  does. 

The  corpuscular  elements  of  ovarian  fluids  are  various.  There  may  be 
oil-globules,  cholesterine  crystals,  blood,  fresh  or  altered,  with  large  gran- 
ular cells. 

Hughes  Bennett,  of  Edinburgh,  and  Drysdale,  of  Philadelphia,  have 
described  a  corpuscle,  seen  at  Fig.  131,  as  characteristic  of  ovarian  fluids. 
According  to  Drysdale,  it  "is  generally  round,  delicate,  transparent,  and 
contains  a  number  of  granules  but  no  nucleus ; "  its  size  varies  from  -^Vo 
of  an  inch  to  ^^o  °f  an  incn  in  diameter.  Acetic  acid  added  to  pus 


AFFECTIONS    OF   THE    FALLOPIAN    TUBES    AND    OVARIES.       215 

makes  the  cells  larger  and  brings  nuclei  into  view ;  while  it  only  increases 
the  transparency  of  the  ovarian  cell  and  makes  its  granules  more  evident. 


Fig.  131. 

Some  cellular  elements  of  ovarian  fluid.  At  the  upper  right-hand  corner  we  have  red  blood-corpuscles. 
Below  these  lie  the  granular  ovarian  cells,  and  below  them  free  granular  matter. 

At  the  upper  left-hand  corner  is  shown  an  epithelial  cell ;  below  it.  a  pus  cell  after  addition  of  acetic 
acid  ;  and  below  this,  pus  cells  before  addition  of  acetic  acid  (Drysdale). 

Parovarian  fluid  is  little  more  than  a  solution  of  salt,  and  to  the  naked 
eye  is  just  like  clear  water.  It  contains  no  cellular  elements. 

SOLID   OVARIAN   TUMOUES  ;    MALIGNANT   TUMOUBS   AND   THE    NATURE   OP    THE 
ASCITIC    FLUID    ASSOCIATED    WITH    THEM. 

Non-malignant  (fibrous '  and  cartilaginous)  tumours  are  rare.  A  tuber- 
cular condition  of  the  ovary  is  found  as  part  of  general  tuberculosis. 

Malignant  disease  of  the  ovary  is  a  comparatively  frequent  occurrence. 
It  often  complicates  cystic  degeneration,  especially  the  papillary  form  of 
ovarian  cyst.  It  arises  also  independently,  and  may  occur  either  in  the 
scirrhus  or  medullary  form.  The  most  important  feature  is  the  rapid  de- 
velopment of  ascites,  without  the  existence  of  cardiac,  hepatic,  or  renal 
disease  to  explain  it.  Of  great  importance  are  the  cells  in  the  ascitic 
fluid  associated  with  malignant  ovarian  disease.  Dr.  Foulis  of  Edinburgh 
has  investigated  this  subject,  and  has  brought  out  results  of  very  great 
value.  Through  his  kindness  we  have  been  able  to  reproduce,  in  Plates 
VI.  and  VII.,  the  cells  he  has  drawn  attention  to  ;  and  he  has  kindly  fur- 
nished us  with  the  following  description : — 

1  In  London  Obst.  Trans. ,  Vol.  XX. ,  p.  276,  is  an  interesting  case  (with  plate)  re- 
ported by  Cullingworth  as  fibroma  of  both  ovaries.  Each  ovary  was  converted  into  a 
solid  nodulated  tumour — one  the  size  of  a  fist,  the  other  larger.  There  was  no  asci- 
tes. The  microscopic  examination  gave  suspicion  of  commencing  sarcoma.  The  lit- 
erature of  fibroma  ovarii  is  fully  given  in  this  paper. 


21 6  MANUAL    OF    QYKECOLOGY. 

"A.  Sprouting  cell  groups  found  in  ascitic  fluid  surrounding  a 
large  cysto-sarcoma  of  the  ovary.  (For  a  history  of  this 
case  see  Edin.  Med.  Jour.,  1875,  p.  838.  In  Figures  3,  4,  5, 
7  great  variation  in  form  and  size  of  the  cells  in  each  group 
is  seen.  The  largest  cells  are  generally  seen  at  the  margins 
of  the  groups.  Fig.  9,  several  large  polynucleated  cells, 
evidently  detached  from  cell  groups.  Fig.  11,  cells  under- 
going fatty  degeneration.  Fig.  12,  blood -corpuscles.) 
"  .B.  Cell  groups  found  in  the  deposit  from  ascitic  fluid  surround- 
ing a  large,  soft,  malignant  tumour  of  the  ovary.  In  many 
of  the  cell-masses  large  vacuoles  are  seen. 

"  C.  Cell  groups  found  in  the  deposit  from  ascitic  fluid  surrounding 
a  large  flat,  or  pancake-shaped,  tumour  of  the  omentum. 
The  tumour  was  thought  to  be  ovarian.  In  the  fluid  in  the 
pleura!  sacs  exactly  similar  cells  and  cell  groups  were  seen, 
and  the  pleural  surface  of  the  diaphragm  was  studded  over 
with  cancerous  nodules. 

"  D.  Cell  groups  found  in  ascitic  fluid  in  the  case  of  a  gentleman, 
aged  seventy,  suffering  from  malignant  peritonitis.  In  the 
centre  a  very  large  cell  mass,  with  numerous  vacuoles  in  the 
substance  of  the  protoplasm,  is  seen. 

"  All  the  cell  groups  and  cells  were  drawn  by  the  aid  of  the 
camera  lucida  under  a  power  of  350  diameters,  with  No.  3 
ocular." 

To  illustrate  the  development  of  the  normal  ovary  and  of  the  Graafian 
follicles,  we  have  added  the  following  figures  from  Foulis'  paper  on  this 
subject : — 

"  E.  Section  through  ovary  and  Wolffian  body  of  a  foetal  lamb,     (a, 
stalk  of  ovary  ;  STB,  strorna  ;  MD,  duct  of  Miiller  ;  e,  epithe- 
lium of  peritoneum  ;  g,  germ  epithelium  ;  y,  deepest  part  of 
the  parenchymatous  zone  of  the  ovary.) 
"  F.  Connective  tissue  sprouting  up  and   surrounding   the   germ 

epithelium." 

It  is  probable  that  these  liberated  cells  found  in  ascitic  fluid  graft 
themselves  on  the  peritoneum,  and  pass  through  the  diaphragm  into  the 
pleura  and  pericardium.  They  behave  just  as  we  have  seen  bacteria  do 
(vide  p.  162). 


PLATE  VH. 


M.D. 


CHAPTER  XXL 
DIAGNOSIS  OF  OVAKIAN  TUMOUES. 

LITERATURE. 

Atlee,  W.  L. — The  General  and  Differential  Diagnosis  of  Ovarian  Tumours :  Lippin- 
cott  &  Co.,  Philadelphia,  1873.  On  Sarcoma  of  the  Ovaries  :  Am.  Gyn.  Tr.,  Vol. 
II.  Barnes — Op.  cit.,  p.  400.  Brown,  J.  Baker — Surgical  Diseases  of  Women  : 
London,  1866.  Duncan,  J.  Mat/lews— Clinical  Lectures  :  London,  Churchill, 
1880.  Hicks,  Braxton — Further  Remarks  on  the  Use  of  Intermittent  Contrac- 
tions of  the  Pregnant  Uterus  as  a  means  of  Diagnosis  :  Lond.  Inter.  Congress  Tr. , 
1882.  Also  Tr.  of  Lond.  Obst.  Soc.,  Vol.  XIII.,  and  Proc.  of  Royal  Soc.  of 
Lond.,  1878.  Jastrebow — On  a  Point  in  the  Diagnosis  of  Ovarian  Tumours  : 
Lond.  Inter.  Congress  Tr.,  1882.  OlsJtausen—Op.  cit.  Ritchie,  C.  G. — Contri- 
butions to  Ovarian  Physiology  and  Pathology :  Churchill,  London,  1865.  Schroeder 
— Op.  cit. ,  S.  Tait,  Lawson — Op.  cit.  Williams,  John — Article,  Ovarian  Tumours : 
Reynolds'  System  of  Medicine,  Vol.  V.  Wells,  T.  Spencer — Diseases  of  the 
Ovaries  :  Churchill,  London,  1872.  Lectures  on  the  Diagnosis  and  Surgical  Treat- 
ment of  Abdominal  Tunuurs:  Br.  Med.  Jour.,  1878. 

FOR  convenience  we  take  up  the  diagnosis  and  differential  diagnosis  of 
ovarian  tumours  under  two  heads : — 

A.  When  small,  and  pelvic  in  position  ; 

B.  When  large,  and  chiefly  abdominal  in  position. 

A.    WHEN   SMALL,    AND    PELVIC    IN    POSITION. 

They  may  be  either  (a)  lateral  to  uterus,  or  (6)  posterior  to  uterus. 

(a.)  Pelvic  Ovarian  Tumours  lateral  to  Uterus. 

1.  Symptoms. — These  are  chiefly  those  of  pressure  and  bearing  down, 
and  have  no  diagnostic  value.     There  is  no  menorrhagia. 

2.  Physical  Signs. — Palpation   and   percussion   give  evidence   of  the 
presence  of  a  tumour  only  when  it  projects  much  above  the  brim.     Aus- 
cultation gives  negative  results.     On  vaginal  examination,  the  cervix  is 


218  MANUAL    OP    GYNECOLOGY. 

found  displaced  to  the  side  opposite  to  that  where  the  tumour  is. 
Through  the  fornix  a  tense,  rounded,  fluctuating  mass  is  felt  projecting 
downwards.  Bimanually  the  uterus  is  felt  not  enlarged,  but  is  displaced 
to  the  one  side  and  is  distinct  from  the  tumour,  which  can  be  mapped 
out  between  the  hands.  Usually  the  uterus  and  tumour  are  not  very 
movable,  owing  to  the  limited  space  of  the  pelvic  cavity.  When  the 
tumour  is  tapped,  ovarian  fluid  is  got. 

3.  Differential  Diagnosis. — When  lateral  to  the  uterus  they  require  to 
be  differentiated  from  the  following : 
(1.)  Pelvic  cellulitis ; 

(2.)  Pelvic  peritonitis  (encysted  serous  effusions) ; 
(3.)  Parovarian  cysts ; 
(4.)  Hydrosalpinx,  Pyosalpinx  ; 
(5.)  Fallopian  tube  gestation  ; 
(6.)  Fibroid  and  fibro-cystic  tumours  of  uterus  ; 
(7.)  Blood  effusion ; 
(8.)  Solid  ovarian  tumours. 

(1.)  Pelvic  Cellulitis. — With  this  we  have  inflammatory  history  and 
probable  cause,  as  abortion  or  labour,  to  guide  us.  When  the  cellulitis 
has  gone  on  to  suppuration,  there  will  be  rigors  and  other  indications  of 
suppuration.  Cellulitic  deposits  are  almost  always  fixed  ;  are  firm  when 
not  purulent,  and  even  when  purulent  do  not  give  very  distinct  fluctuation. 
(2.)  Pelvic  Peritonitis. — This  will  not  cause  the  fornix  to  bulge  down- 
wards, and  the  history  will  help  us.  Tapping  gives  serum,  and  not 
ovarian  fluid.  When  an  ovarian  tumour  is  fixed  by  peritonitic  adhesions, 
it  will  be  almost  impossible  to  diagnose  it  from  encysted  pelvic  peritonitic 
effusion  except  by  examination  of  the  fluid. 

(3.)  Parovarian  cysts  are  not  so  rounded  and  have  very  distinct  fluc- 
tuation ;  their  secretion  is  simple  salt  and  water,  and  when  tapped  they 
do  not  recur. 

(4.)  Hydrosalpinx  and  pyosalpinx  are  high  in  pelvis,  tortuous,  elon- 
gated from  side  to  side. 

(5.)  Fallopian  tube  gestation  (v.  extra-uterine  gestation  under  Section 
IX.). 

(6.)  Fibroid  and  fibro-cystic  tumours  of  uterus  (v.  Section  V.). 
(7.)  Blood  effusion  in  the  broad  ligaments  is  difficult  to  diagnose  dur- 
ing life,  and  is  chiefly  discovered  on  operation  or  post-mortem.     The 
same  is  true  of  Hrematometra. 


AFFECTIONS    OF    THE    FALLOPIAN   TUBES   AND    OVARIES.       219 

(8.)  Solid  ovarian  tumours  are  rare.  When  malignant  there  are  often 
nodules  in  the  fornices  and  ascitic  fluid  which  shows  the  cells  shown  at 
Plates  VI.  and  VIL 

6.  Pelvic  Ovarian  Tumours  posterior  to  Uterus. 

1.  Symptoms. — The  most  striking  one  is  associated  with  urination ; 
there  is  either  retention  or  constant  desire  to  micturate.     There  is  no 
menorrhagia. 

2.  Physical  Signs. — Palpation,  auscultation,  and  percussion  give  the 
same  result  as  when  the  tumour  is  lateral.     On  bimanual  examination, 
the  uterus  is  felt  markedly  displaced  to  the  front,  but  is  not  enlarged  ; 
and  bulging  downwards  behind  the  cervix,  the  round  globular  cystic 
ovary  can  be  grasped.     Tapping  gives  ovarian  fluid. 

3.  Differential  Diagnosis. — When  posterior  to  the  uterus,  they  require 
to  be  differentiated  from  the  following  conditions. 

(1.)  Encysted  serous  peritonitic  effusion, 
(2.)  Retro-uterine  hsematocele, 
(3.)  Fibroid  and  fibro-cystic  tumours  of  the  uterus, 
(4.)  Ketroverted  gravid  uterus  and  extra-uterine  foetation, 
(5.)  Parovarian  cysts. 

(1.)  Peritonitic  effusion  has  an  inflammatory  history;  it  is  not  so 
rounded  nor  so  well  defined  above.  The  fluid  is  serous. 

(2.)  Retro-uterine  hcematocele  has,  after  the  blood  has  coagulated,  a 
hard  feeling  and  is  more  expanded  transversely.     There  is  a  history  of 
sudden  onset,  menorrhagia,  and  subsequent  inflammatory  symptoms. 
(3.)  Fibroid  and  fibro-cystic  tumour  of  the  uterus  (v.  Section  V.). 
(4.)  Retroverted  gravid  uterus  and  extra  uterine  foetation  (v.  Section  IX.). 
(5.)  Parovarian  Cysts.— The  character  of  the  fluid  is  our  only  certain 
guide. 

It  should  be  specially  noted  that  these  pelvic  ovarian  tumours  are  apt 
to  cause  pelvic  inflammation  and  thus  render  the  exact  diagnosis,  unless 
aided  by  tapping,  very  difficult 

B.     DIAGNOSIS   OF   OVARIAN   TUMOURS   WHEN    LARGE,    AND   CHIEFLY  ABDOMDIAL 

IN   POSITION. 

1.  Symptoms — These  are  chiefly  due  to  its  bulk.  The  patient's  notice 
is  attracted  to  the  fact  that  she  is  getting  rapidly  stout.  Recently,  Jas- 


220 


MANUAL    OF    GYNECOLOGY. 


trebow  has  alleged  that  the  sensibility  of  that  part  of  the  groin  supplied 
by  the  genito- crural  nerve  is  impaired  on  the  same  side  as  that  on  which 
the  tumour  is. 

2.  Physical  Signs. — When  the  patient  lies  on  her  back  and  the  abdom- 
inal surface  is  bared,  the  following  points  can  be  noted. 

On  inspection  the  abdomen  is  seen  to  be  greatly  distended.  The  dis- 
tention  may  be  uniform,  but  is  often  more  or  less  markedly  lateral  The 
distance  from  the  anterior  superior  spinous  process  to  the  umbilicus  is 
greater  on  one  side  than  the  other.  The  superficial  abdominal  veins  may 
be  dilated,  and  lineae  albicantes  are  sometimes  present. 

On  palpation,  the  distention  is  felt  to  be  due  to  an  encysted  collection 
of  fluid.  A  mass  is  felt  in  the  abdominal  cavity  which  is  like  a  sac  filled 


Pig.  132. 
The  shaded  portion  shows  the  dull  area;  left  figure— ovarian  tumour,  right  figure— ascites  (Barnes). 

with  fluid.  Fluctuation  is  got  by  placing  one  hand  at  a  special  part  and 
tapping  at  an  opposite  point  with  the  fingers  of  the  other  hand.  How- 
ever long  the  tumour  be  manipulated,  there  is  never  felt  any  muscular  con- 
traction of  the  cyst-wall. 

On  percussion  when  the  patient  lies  dorsal,  a  dull  note  is  obtained 
over  the  tumour  (Fig.  132)  ;  but  at  the  flank,  where  the  tumour  does  not 
bulge,  it  is  clear  and  tympanitic,  since  the  intestines  are  there.  When 
the  patient  turns  on  her  side,  with  this  flank  uppermost;  the  dulness  and 


AFFECTIONS    OF   THE    FALLOPIAN    TUBES    AND    OVARIES.       221 

tympanitic  note  do  not  change  in  position.     This  sign  shows  we  have  to 
deal  with  an  encysted  collection  of  fluid. 

Auscultation  gives  entirely  negative  results.  No  sound  is  heard  unless 
that  of  friction  over  a  localized  peritonitis. 

On  vaginal  examination,  the  uterus  is  felt  displaced  to  one  or  other 
side,  or  very  much  to  the  front.  It  is  rarely  retroverted,  and — unless  im- 
pregnated— is  not  enlarged.  The  tumour  does  not  usually  bulge  down 
into  the  fornices,  but  may  be  made  out  birnanually. 

In  order  to  ascertain  how  the  pedicle  lies,  we  have  to  make  the  exami- 
nation per  rectum.  The  tumour  is  drawn  upwards  in  the  abdominal  cav- 
ity by  an  assistant.  We  now  lay  hold  of  the  cervix  with  a  volsella,  pass 
the  index  finger  of  the  right  hand  into  the  rectum,  make  traction  on  the 
cervix  till  the  fundus  is  brought  within  reach  of  the  rectal  finger.  We 
recognize  a  tense  band  passing  from  one  angle  of  the  fundus,  and  the  en- 
larged ovarian  artery  may  be  felt  pulsating  in  it.  We  now  examine  for 
the  ovary  of  the  opposite  side  ;  this  is  ascertained  to  be  normal  in  size. 
The  possibility  of  both  ovaries  being  cystic  (which  would  produce  a  pedi- 
cle on  each  side)  should  not  be  forgotten,  though  this  is  comparatively 
rare.  The  examination  with  the  volsella  is  made  easier  by  placing  the 
patient  in  the  genu-pectoral  posture ;  the  weight  of  the  tumour  makes  it 
gravitate  into  the  abdomen,  and  renders  the  pedicle  tense  ;  it  is  also  easier 
to  make  the  rectal  examination  in  this  position. 

3.  Differential  Diagnosis  of  Abdominal  Ovarian  Tumours. 
They  must  be  diagnosed  from  the  following  conditions : — 
(1.)  Pregnancy  and  Hydramnios, 
(2.)  Fibroma  uteri, 
(3.)  Ascitic  fluid, 

(4.)  Fibrocystic  tumours  of  the  uterus, 
(5.)  Parovian  tumours, 
(6.)  Encysted  dropsy, 

(7.)  Thickened  omentum  enclosing  intestines  by  adhesions, 
(8. )  Omental  tumours, 
(9.)  Renal  tumours, 
(10.)  Hydatid  of  liver, 
(11.)  Pseudocyesis, 
(12.)  Distended  bladder. 

In  observing  a  case  of  abdominal  tumour,  the  student  makes  first  his 
positive  examination  systematically  ;  he  makes  in  every  case  what  is  called 


222  MANUAL    OF    GYNECOLOGY. 

the  routine  examination,  noting  what  he  observes.  By  this  means  he 
may  get  facts  enough  to  warrant  his  drawing  a  distinct  conclusion  as  to  its 
nature.  This,  however,  is  not  always  the  case  ;  he  has  then  to  use  diag- 
nosis by  exclusion  ;  it  must  be  one  of  a  certain  fixed  number  of  things  ; 
the  possibilities  are  excluded  one  by  one  till  a  definite  diagnosis  is  reached. 

We  have  stated  above  that  ovarian  tumours  require  to  be  diagnosed 
from  twelve  conditions.  On  each  of  these  we  make  some  brief  remarks. 

Pregnancy. — At  the  period  of  pregnancy,  when  the  uterus  is  so  enlarged 
as  to  be  above  the  pelvic  brim,  certain  conditions  are  present.  These  are 
suppression  of  menstruation  for  a  given  period,  and  size  of  the  uterus  cor- 
responding to  this ;  mammary  signs  ;  linese  albicantes,  and  pigmentation. 
On  palpation,  we  feel  a  tumour  without  distinct  fluctuation  and  having  in- 
termittent contractions  ;  the  foetus  can  be  palpated  out.  The  foetal  heart 
(after  the  fourth  month)  and  the  uterine  souffle  are  heard.  The  vagina  is 
dark  in  color,  the  mucous  secretion  increased,  and  the  cervix  soft. 

We  need  hardly  say  that  the  palpation,  the  foetal  heart-sounds,  bruit 
and  vaginal  changes  mark  out  the  pregnancy  unmistakably.  These  points 
may  seem  too  simple  to  require  mention,  but  cases  have  been  recorded 
where  the  pregnant  uterus  has  been  tapped  for  an  ovarian  cyst. 

Hydramnios  may  simulate  an  ovarian  cyst.  The  amenorrhcea  will  help, 
and  especially  the  occurrence  of  intermittent  contractions  asBraxtonHicks 
has  specially  pointed  out.  In  one  of  his  recorded  cases,  the  tumour  was 
the  size  of  a  seven  months'  uterus  with  distinct  fluctuation,  and  there  was 
amenorrhoea  for  five  months.  Palpation  gave  the  uterine  hardening.  Pre- 
vious to  this  it  had  been  tapped  as  a  cystic  ovarian  tumour. 

(2.)  Fibroma  uteri  (v.  Section  V.). 

(3.) — Ascitic  Fluid. — When  the  patient  lies  on  her  back,  percussion 
gives  a  tympanitic,  note  at  the  umbilicus  and  a  dull  one  at  the  flanks  (Fig. 
132)  ;  when  on  her  left  side,  the  note  is  dull  on  that  side  and  clear  over 
the  right ;  when  on  her  right,  it  is  dull  on  that  side  and  tympanitic  on  the 
left ;  when  she  sits  up,  the  upper  limit  of  the  dulness  is  curved  with  the 
convexity  downwards. 

The  reason  of  this  is  evident.  The  intestines  float  on  the  fluid  at  its 
highest  point  and  give  the  tympanitic  note  accordingly  (Fig.  132). 

(4.)  Fibrocystic  tumours  of  the  uterus  are  difficult  to  diagnose.  The 
following  points  should  be  noted.  Fluctuation  is  only  partial,  and  the 
consistence  is  variable  ;  the  rate  of  growth  is  slower  ;  and  the  fluid  drawn 
off  coagulates  spontaneously.  It  is  often  difficult  to  separate  these  from 


AFFECTIOXS    OF    THE    FALLOPIAN    TUBES    AND    OVARIES.        '2*23 

ovarian  tumours,  and  the  best  operators  have  sometimes  failed  to  do  so  (c. 
Section  V.). 

(5.)  Parovarian  tumours  have  very  well-marked  fluctuation,  have  their 
characteristic  fluid,  and* when  once  tapped  do  not  refill,  as  they  are  mere 
retention  cysts. 

(6,  7,  and  8.)  In  many  cases  we  can  make  out  that  the  tumour  does 
not  pass  down  into  the  pelvis  and  is  not  connected  with  the  uterus. 
Sometimes  the  case  is  obscure,  and  abdominal  incision  alone  clears  mat- 
ters up. 

(9.)  Renal  tumours  grow  downwards  and  inwards.  "When  right-sided, 
the  tympanitic  colon  lies  between  them  and  the  liver.  Their  fluid  con- 
tains urea. 

(10.)  The  connection  of  the  hydatid  with  the  liver  can  be  made  out. 

(11.)  In  Pseudocyesis  the  percussion  note  is  tympanitic,  and  the  swell- 
ing disappears  under  chloroform. 

(12.)  The  distended  bladder  is  of  course  emptied  by  the  catheter. 

DIAGNOSIS    OF    ADHESIONS. 

When  pelvic,  the  thickening  they  cause  can  be  felt.  Tappings  arc 
one  great  cause  of  adhesions  ;  they  may  also  arise  from  mere  pressure. 
Careful  inquiry  should  always  be  made  as  to  the  history.  On  palpating 
the  tumour,  one  can  often  feel  friction.  On  making  the  patient  take  a 
deep  breath,  it  should  be  noted  whether  the  abdominal  walls  move  over 
the  surface  of  the  tumour.  Much  less  importance  is  attached  now-a-dayn 
to  the  existence  of  abdominal  adhesions.  "When  pelvic,  especially  if  to 
the  bladder  or  deep  in  the  pouch  of  Douglas,  they  are  more  serious. 

COEXISTENCE    <  >F    PREGNANCY    AND    OVARIAN    TUMOTR. 

It  should  be  kept  in  mind  that  pregnancy  may  coexist  with  an  ovarian 
tumour,  giving  its  own  special  symptoms  and  physical  signs  in  addition. 


CHAPTEE    XXII. 
OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS. 

LITEKATUBE. 

Atlee — Op.  cifc.  Bantock — First  Series  of  Twenty-five  Cases  of  Completed  Ovariotomy  : 
Brit.  Med.  Jour.,  1879,  p.  766.  Cheyne,  Watson — Antiseptic  Surgery:  Smith, 
Elder  &  Co.,  London,  1882.  Hegar  and  Kaltenbach — Die  operative  Gynakologie : 
Stuttgart,  1881,  S.  201.  Lister — Address  on  the  Treatment  of  Wounds  :  Lancet, 
Nov.  19  and  26,  1881.  Miner — Ovariotomy  by  Enucleation  :  Philad.  Intern. 
Cong.  Tr.,  1877.  Munde,  P.  F.—  The  Value  of  Electrolysis  in  the  Treatment  of 
Ovarian  Tumours:  Am.  Gyn.  Tr. ,  Vol.  II.,  p.  348.  Sims,  J.  M. — Thomas  Keith 
and  Ovariotomy:  Am.  Jour,  of  Obst.,  April,  1880.  Tait,  Lawson—On  Axial 
Rotation  of  Ovarian  Tumours  leading  to  their  Strangulation  and  Gangrene :  Lon- 
don Obst.  Tr..  Vol.  XXII.,  p.  86.  The  Antiseptic  Theory  tested  in  Ovariotomy: 
Lond.  Med.  Chir.  Tr.,  Vol.  LXIII. ,  p.  161.  Recent  Advances  in  Abdominal  Sur- 
gery: London  Intern.  Cong.  Tr.,  1882.  Thornton — The  Silk  Ligature  as  a  Means 
of  Securing  the  Ovarian  Pedicle:  Brit.  Med.  Jour.,  1878,  p.  125.  Wells,  T.  S.— 
Op.  cit.  Recent  Advances  in  the  Surgical  Treatment  of  Intraperitoneal  Wounds  : 
London  Intern.  Cong.  Tr.,  1882.  Additional  Cases  of  Ovariotomy  performed 
during  Pregnancy :  London  Obst.  Tr.,  Vol.  XIX.,  p.  184. 

KEMOVAL  of  the  ovarian  tumour  by  abdominal  or  vaginal  section — in  almost 
all  cases  abdominal — is  the  treatment  now  practised.  Other  methods 
have,  however,  been  employed  ;  a  brief  resume  of  these  will  be  useful  to 
the  student. 

These  methods  have  been  tapping,  tapping  and  injection  of  the  cyst 
with  iodine,  electrolysis,  drainage  into  the  peritoneal  cavity  or  through 
the  vagina. 

Tapping  is  not  a  method  of  treatment  followed  by  cure,  and  should  be 
used  only  when  it  is  necessary  to  obtain  fluid  for  diagnosis.  It  cures 
parovarian  cysts,  as  these  are  mere  retention  cysts.  Ovarian  cysts  are  not 
retention  cysts,  but  have  a  proliferating  lining  membrane,  for  which  rea- 
son tapping  does  not  cure  them.  An  additional  reason  against  tapping  is 
that  it  is  a  procedure  by  no  means  free  from  danger,  even  to  life.  By 


AFFECTIONS    OF   THE    FALLOPIAN   TUBES    AND    OVARIES.       225 

oozing  of  the  fluid  through  the  puncture,  adhesions  are  set  up  ;  in  some 
cases,  septic  peritonitis  has  proved  fatal.  Tapping,  further,  is  only  palli- 
ative and  must  be  followed  by  ovariotomy. 

Method  of  Tapping. — See  that  the  bladder  is  empty.  "With  the  patient 
lying  on  her  back  make  an  incision  through  skin  and  fat  for  about  an 
inch,  and  midway  between  umbilicus  and  pubis.  Then  plunge  in  the 
trocar  seen  at  Fig.  134.  To  the  side -tube  a  long  piece  of  tubing  is  at- 
tached, which  dips  under  water.  While  the  fluid  is  flowing,  the  patient 
lies  on  her  side.  No  bandage  is  necessary.  Care  should  be  taken  to  pre- 
vent regurgitation  of  air,  and  a  suitable  dressing  should  be  applied  to  the 
wound  (cide  under  Ovariotomy). 

Tapping  and  injection  of  the  cyst  with  iodine  is  a  procedure  not  now 
practised,  owing  to  the  risks  and  uncertainty  attending  it. 

Electrolysis  was  at  one  time  advocated  as  a  means  of  cure.  Its  pre- 
tensions to  this  are  unfounded,  and  no  operator  now  practises  it.  Its  use 
has  been  carefully  considered  by  Munde  of  New  York  in  the  article  cited, 
which  may  be  consulted  for  details  and  information. 

Drainage  into  the  Peritoneal  Cavity  or  through  the  Vagina. — The  former 
is  dangerous,  and  the  latter  is  only  practised  in  those  cases  where  the 
cvst  is  immovably  fixed  by  adhesions. 

One  fact  must  be  finally  noted.  Cases  of  cure  of  ovarian  cysts  by 
tapping,  drainage,  or  electrolysis,  are  sometimes  recorded.  These  cysts 
have  probably  not  been  ovarian,  but  cysts  of  the  broad  ligament — paro- 
varian.  Mere  tapping  often  cures  the  latter.  Electrolysis  does  the  same. 
Electricity  has  nothing  to  do  with  it,  the  puncture  of  the  needle  is  enough. 

OVARIOTOMY. 

This  is  performed  by  vaginal  or  by  abdominal  incision.  The  former  is 
very  rarely  employed,  the  latter  is  the  usual  method. 

VAGINAL  METHOD. 

This  may  be  practised  when  the  tumour  is  pelvic  and  small.  Thomas 
of  New  York,  Goodell  of  Philadelphia,  Gilmore,  Hamilton  and  others 
have  recorded  cases.  The  following  is  the  plan  of  procedure  : 

Chloroform  or  etherize  the  patient.  Place  her  semiprone  or  in  the 
lithotomy  posture.  Pass  the  Sims  speculum.  Incise  the  posterior 
vaginal  wall  behind  the  cervix,  in  the  middle  line.  Tap  the  tumour  with 
VOL.  I.— 15 


226  MANUAL    OF    GYNECOLOGY. 

an  aspirator,  and  then  draw  it  through  the  incision  with  the  finger  or 
curved  forceps.  Ligature  the  pedicle  with  thin  carbolized  silk  threaded 
on  a  handled  needle,  and  divide  it  on  the  distal  side.  Pass  a  T-shaped 
drainage-tube  into  the  wound,  which  may  be  stitched  round  it  or  left  open. 
Should  the  temperature  rise  or  the  discharge  become  fetid,  irrigate  daily 
with  weak  carbolic  lotion  (1-100). 

Encouraging  results  have  been  got  by  this  method. 

• 

ABDOMINAL  METHOD. 

These  questions  are  often  asked  :  When  is  the  best  time  to  operate  on 
an  ovarian  tumour  ?  Should  it  be  removed  when  small,  or  should  the 
operator  wait  until  it  is  of  good  size  ?  If  the  latter,  how  large  should  it  be  ? 
It  is  better  not  to  operate  by  this  method  when  the  tumour  is  small, 
but  to  wait  until  its  size  is  that  of  a  six  months'  or  nine  months'  pregnancy. 
A  tumour  of  this  size  has  displaced  the  small  intestine  from  its  usual 
position  behind  the  anterior  abdominal  wall,  and  has  stretched  and 
thinned  out  somewhat  the  latter.  The  abdominal  incision  is  therefore 
more  easily  made  and  the  intestines  are  out  of  harm's  reach.  Of  course  it 
should  not  be  forgotten  that,  when  the  medical  man  is  consulted,  ovarian 
tumours  have  usually  become  abdominal  and  large. 

Let  us  suppose,  then,  that  the  ovariotomist  has  a  patient — who  is  other- 
wise healthy — with  an  ovarian  tumour  free  from  adhesions,  and  that  her 
period  has  occurred  ten  days  before.  How  is  the  operation  performed  ? 

If  the  patient  has  not  been  in  any  way  confined  to  bed,  it  is  probably 
better  to  delay  the  operation  till  another  period  has  passed,  in  order  to 
accustom  her  to  an  invalid's  life.  She  is  kept  on  light  diet,  and  has  no 
solid  food  for  six  hours  previous  to  the  administration  of  chloroform.  On 
the  evening  prior  to  the  operation,  castor-oil  should  be  given  and  an  enema 
used  in  the  morning. 

The  following  are  the  requisites  for  operation  : 
Chloroform  and  ether  ; 
Hypodermic  syringe ; 
Spray  ; 

Carbolic  lotion  ; 

Porcelain  trays  for  instruments  ; 

Sponges  (a  definite  number),  some  small  and  fixed  on  sponge- 
holders  ; 


AFFECTIONS    OF    THE    FALLOPIAX    TUBES    AND    OVARIES.       2 2 7 

Waterproof,  with  oval  opening,  of  which  the  edges  are  coated 
with  adhesive  plaster  ; 

Ordinary  knives  ; 

Probe-pointed  curved  bistoury  ; 

Scissors,  straight  and  curved  ; 

Spatula*  ; 

Dissecting  and  dressing  forceps  ; 

Pean's  or  Wells'  artery  forceps— a  definite  number  (20)  of 
pairs  ; 

Tenacula,  blunt  hooks  ; 

Needles  on  fixed  handles  ; 

Aneurism  needle  ; 

Fine  catgut  for  bleeding  vessels  ; 

Carbolised  silk  (Nos.  3  and  4)  ; 

Two  pair  ovariotomy  forceps  (Xelaton's  or  Keith's)  ; 

Wells'  trocar  ; 

Clamp  (in  reserve)  ; 

Cautery,  actual  or  Paquelin's  ; 

Cautery-clamp  ; 

Long  straight  needles,  threaded  two  on  each  suture  of  silk- 
worm-gut ; 

Needle-holder  with  small  needles  on  horse-hair  sutures  ; 

Drainage-tubes  (glass  or  ordinary)  ; 

Carbolic  gau/e,  protective  silk,  mackintosh.  Hannel  bandages. 
The  assistants  necessary  are  live  or  six  in  number,  viz.,  one  for  chloro- 
form, one  for  instruments,  one  to  help  the  operator,  one  to  look  after  the 
spray,  and  one  for  the  cautery.  A  trained  nurse  who  can  pass  the  catheter 
and  administer  purgative  or  nutritive  enemata,  is  necessary.  The  patient 
is  placed  on  an  ordinary  table,  of  convenient  height  and  length,  and  1;<  s 
on  her  back.  The  table  is  placed  so  that  the  patient's  feet  are  towards 
the  window.  The  legs  and  chest  are  to  be  warmly  covered,  and  hot- 
water  bottles  should  be  laid  at  her  side  and  feet.  The  room  should  be 
comfortably  warm.  The  best  position  for  the  operator  is  to  stand  on  the 
patient's  right  side,  with  his  back  to  her  feet  and  to  the  window.  The 
question  of  the  use  of  antiseptics  in  ovariotomy  will  be  discussed  after- 
wards. The  instruments  are  placed  near  the  operator  in  shallow  porce- 
lain trays,  and  in  1  -40  carbolic  solution. 

The   sponges   should    be   soft,  line,    and   thoroughly    clean.      Seven    or 


228  MANUAL    OF    GYNECOLOGY. 

eight  are  sufficient.  Some  are  small  and  on  sponge-holders  ;  one  is  large 
and  flat.  They  should  be  thoroughly  wrung  out  of  warm  1-60  solution. 
The  sponge  assistant  should  know  how  many  sponges  he  has,  and  should  be 
sure  that  he  has  recovered  them  all  before  the  abdominal  wound  is  closed. 
Sponges  should  never  on  any  account  be  torn  up  during  an  operation. 

The  spray,  if  used,  should  be  placed  eight  or  ten  feet  from  the  wound, 
and  should  throw  out  a  finely  divided  vapour. 

Preliminaries. — The  patient,  who  has  had  a  very  light  breakfast  some 
hours  previously,  should  be  chloroformed  ;  the  skin  washed  and  shaved  ; 
and  the  waterproof  made  to  adhere  to  the  skin,  so  that  the  incision  shall 
bisect  the  portion  exposed  through  the  oval  opening.  This  waterproof 
keeps  the  patient  dry  and  comfortable. 

The  following  are  the  steps  of  an  ordinary  operation  :  — 

1.  The  abdominal  incision  ; 

2.  Evacuation  of  the  cyst  contents  ; 

3.  Drawing  out  of  the  cyst  from  the  abdomen ; 

4.  Its  separation  at  the  pedicle  ; 

5.  Treatment  of  adhesions,  and  bleeding  from  them  ; 

6.  The  peritoneal  toilette  ; 

7.  Closure  of  the  abdominal  wound ; 

8.  Drainage — when  necessary  ; 

9.  Dressing  of  the  wound ; 

10.  After-treatment — complications. 

1.  The  Abdominal  Incision. — This  is  usually  four  or  five  inches  long,  is 
made  in  the  middle  line,  and  has  its  lower  limit  about  an  inch  above  the 
symphysis.  It  passes  through — 

skin, 

fat, 

line  a  alba, 

fascia  transversalis, 

extraperitoneal  fat, 

peritoneum. 

Sometimes  the  linea  alba  is  missed,  and  the  rectus  muscle  cut  into. 
By  passing  a  probe  in  towards  the  middle  line,  the  operator  gets  the 
right  track  and  thus  avoids  bleeding.  The  extraperitoneal  fat  is  a  good 
landmark.  All  bleeding  points  are  carefully  attended  to  before  the  peri- 
toneum is  opened.  They  may  be  seized  with  Pean's  forceps,  which  are 
left  on  for  a  time,  or  they  may  be  ligatured  with  catgut.  When  the 


AFFECTIONS    OF   THE    FALLOPIAN   TUBES    AND    OVARIES.       229 

smooth  shining  peritoneum  is  reached,  it  should  be  hooked  up  with  a  fine 
tenaculum  and  cut  into.     The  cyst- wall  is  now  exposed. 

2.  Evacuation  of  the  Cyst  Contents. — This  may  be  accomplished  in  vari- 
ous ways.     Wells'  trocar  (Fig.  133),  with  its  point  projected,  is  plunged 


Wells'  Trocar 


).    CT,  sharp  point,  protected  by  tube  6,  which  is  projected  by  pushing  out  thumb-piece  d  ; 
c,  toothed  catch  to  grasp  cyst-wall  ;  gutta-percha  tubing  is  fitted  on  to  e. 


in,  and  the  fluid  passes  along  the  thick  tube  to  a  suitable  pail  below  the 
table.  As  soon  as  the  trocar  enters  the  eyst,  the  shield  is  pushed  out  to 
guard  the  point.  The  trocar  has  teeth  for  catching  up  the  cyst-wall. 
Keith  uses  a  large  aspirator,  so  as  to  empty  speedily.  Schroeder  uses  no 
trocar,  but  simply  cuts  in  with  his  knife  and  squeezes  the  fluid  out.  The 
kneed  trocar  may  be  used  (Fig.  134).  When  the  fluid  is  very  thick  it  may 


Fig-  134. 
Trocar  for  tapping.     Tubing  is  fitted  to  side  piece. 

not  flow,  and  have  to  be  squeezed  or  scooped  out.  Secondary  cysts,  if 
large,  are  also  perforated. 

While  the  fluid  is  being  evacuated  an  assistant  keeps  up  steady  press- 
ure on  the  abdominal  walls,  in  order  to  prevent  the  intestines  from  pass- 
ing out. 

3.  Draining  out  of  the  Cyst  from  the  Abdomen.— This  is  accomplished  by 
seizing  the  collapsed  walls  of  the  tumour  with  Nekton's  (Fig.  135)  or 
Keith's  forceps,  and  steadily  pulling  it  out.  The  assistant  still  keeps  up 
pressure.  By  this  means,  the  operator  now  has  the  pedicle  at  the  abdom- 
inal incision,  and  the  cyst  outside. 


230 


MANUAL    OF    GYNECOLOGY. 


4.  Its  Separation  at  the  Pedicle. — This  is  one  of  the  most  important  steps 
of  the  operation.     There  are  three  methods  which  may  be  used,  -viz. — 

The  clamp, 
The  cautery, 
The  ligature. 
Of  these,  the  clamp  is  now  seldom  used.     Keith  and  others  advocate 


Fig.  135. 

N61aton's  forceps. 

the  cautery ;  "but  the  ligature  and  dropping  back  of  the  pedicle  is  the 
favourite  and  probably  the  best  method. 

The  clamp  was  introduced  by  Jonathan  Hutchinson,  but,  as  already 
said,  is  now  yielding  to  the  ligature.  The  varieties  of  clamp  are  numer- 
ous. Fig.  136  shows  Wells' ;  it  consists  of  two  short  arms  jointed  to- 


Wells'  clamp  (}£),  with  removable  handles.    The  serrated  part  with  the  screw  Is  the  clamp  proper. 

gether  and  provided  with  a  screw  and  removable  handles.     It  is  used  as 
follows : 

The  clamp  is  held  by  its  handles  and  made  to  grasp  the  pedicle  be- 
tween the  cyst  and  the  uterus ;  the  bars  of  the  clamp  proper  are  then 
approximated,  and  the  screw  tightly  screwed  up.  The  pedicle  is  exam- 
ined to  see  that  it  is  grasped  and  equally  compressed  ;  if  one  part  is  thin, 
Spencer  Wells  recommends  that  the  pedicle  be  first  secured  with  a  liga- 
ture. The  pedicle  is  treated  extra-peritoneally  with  the  clamp  which 
rests  on  the  skin.  The  great  advantage  of  the  clamp  is  its  security 


AFFECTIONS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES.   231 

against  hemorrhage.  Its  evident  disadvantages  are  the  following :  it 
does  not  suit  all  cases,  as  it  cannot  be  used  when  the  pedicle  is  too  large 
or  too  short ;  it  may  cause  ventral  hernia  ;  it  exercises  undue  traction  on 
the  uterus ;  but,  above  all,  it  may  cause  a  slough  deeper  down  than  the 
skin,  and  the  discharges,  passing  into  the  peritoneal  cavity,  may  do  great 
mischief. 

The  cautery  was  introduced,  as  a  means  of  treating  the  pedicle,  by 
Baker  Brown  of  London.  It  gives  better  results  than  the  clamp. 

In  order  to  use  the  cautery,  we  need  a  special  cautery-clamp  and 
either  cautery  irons  or  Paquelin's  cautery.  Keith  uses  ordinary  cautery 
irons  heated  in  a  little  charcoal  brazier.  The  cautery-clamp  has  two 
hinged  bars  provided  with  handles ;  each  bar  has  one  surface  which  is 
made  of  ivory — a  non-conductor — and  is  placed  next  the  skin  ;  the  other 
surface  is  made  of  metal ;  one  of  the  bars  has  on  its  metal  surface  a  metal 
upright  running  the  whole  length  of  the  bar.  The  pedicle  is  seized  with 
the  clamp  (ivory  side  next  to  the  skin),  and  the  screw  turned  to  fix  it. 
Then  the  cyst  is  cut  off,  so  as  to  leave  about  an  inch  of  the  pedicle  on  the 
metal  side.  The  dull  cautery  iron,  which  is  hatchet-shaped,  is  then 
passed  firmly  over  the  surface,  in  the  angle  between  the  horizontal  bar 
and  the  upright,  until  the  pedicle  is  seared  flush  with  the  clamp.  The 
pedicle  is  now  caught  at  the  under  surface  of  the  clamp  with  two  pairs  of 
forceps,  and  the  clamp  removed.  If  all  is  right,  it  is  dropped  into  the 
abdomen  after  the  peritoneal  toilette  is  finished. 

The  ligature  should  be  thin  carbolised  Chinese  silk,  No.  3  or  4.  It  is 
used  in  the  following  way  : 

A  double  silk  ligature  is  threaded  on  a  blunt  needle.  The  pedicle  is 
transfixed  with  this,  and  the  ligature  cut.  Thus  we  have  two  ligatures 
through  the  pedicle  ;  one  is  passed  round  the  one  half  of  the  pedicle,  the 
other  round  the  other  half.  They  may  be  made  to  interlace  first  so  as  to 
make  a  figure  of  eight.  Each  is  tied  firmly  in  a  reef  knot.  The  pedicle 
is  then  seized  with  Pean's  forceps,  one  on  each  side  just  below  the  lig- 
ature ;  the  cyst  is  clipped  off  about  half  an  inch  on  the  cyst  side  of  the 
ligature  ;  as  the  pedicle  is  still  held  up  by  the  forceps  it  can  be  carefully 
examined  to  see  if  any  bleeding  occurs.  It  should  be  noted  whether  the 
ligature  splits  the  pedicle  vertically  so  as  to  cause  bleeding ;  if  so,  the 
ends  of  the  thread  can  be  made  to  surround  the  whole  pedicle  below  this. 
If  there  is  no  bleeding,  the  ligature  is  cut  short  and  the  pedicle  dropped 
into  the  pelvis. 


232  MANUAL    OF    GYNECOLOGY. 

The  raw  end  of  the  pedicle  may  be  stitched  with  catgut  to  the  broad 
ligament,  so  as  to  prevent  its  adhering  to  and  Constricting  intestine 
(Thornton). 

When  the  pedicle  is  thick  and  fleshy  it  may  require  to  be  tied  in  three 
portions  as  follows  : — Pass  a  double  thread  so  that  its  shorter  half  will 
embrace  only  one-third  of  the  pedicle  ;  withdraw  the  needle,  but  keep  it 
still  running  on  the  thread,  and  use  it  to  carry  the  longer  half  of  the 
thread  through  at  a  second  point,  so  as  to  embrace  the  middle  third  of  the 
pedicle  ;  one  portion  of  the  longer  half  thus  forms  a  loop  round  the  mid- 
dle third,  while  the  other  portion  embraces  the  other  third  of  the  pedicle. 

After  the  pedicle  has  been  secured  by  one  of  these  methods,  the  other 
ovary  should  be  examined,  and  if  cystic  removed  also. 

The  distal  portion  of  the  pedicle  does  not  slough  ;  according  to  Thorn  • 
ton  we  may  have  the  five  following  results. 

(1.)  Adhesion  of  the  peritoneal  surfaces  on  opposite  sides  of  the  lig- 
ature, and  absorption  of  ligature. 

(2.)  Lymph  effused  over  ligature  and  end  of  stump,  formation  of  new 
vessels. 

(3.)  Adhesion  of  pedicle  raw  surface  to  some  neighbouring  peritoneal 
surface  and  passage  of  blood-vessels  between. 

(4.)  Hemorrhage  from  pampiniform  plexus  at  outer  edge. 

(5.)  No  change  or  sloughing  if  patient  dies  soon. 

5.  Treatment  of  Adhesions  and  Bleeding. — The  adhesions,  in  certain 
cases,  may  give  a  great  deal  of  trouble.  They  may  be  at  any  point  of  the 
periphery  of  the  tumour.  When  close  to  important  viscera — especially 
the  bladder,  intestine,  or  liver — they  are  serious.  Their  treatment  is  best 
considered  as  follows  :  (a)  when  short,  (&)  when  long. 

(a.)  When  they  are  short  and  connected  with  the  anterior  abdominal 
wall,  the  cyst  is  sometimes  cut  into.  The  operator  then  separates  the 
cyst  from  the  wall,  by  passing  his  finger  in  between  them  where  the  ad- 
hesion ceases  ;  or  he  may  evert  the  abdominal  wall,  and  strip  the  cyst  off 
it  with  dissecting  forceps.  Spencer  Wells  recommends  in  bad  cases  to 
evacuate  the  cyst,  and  then,  by  seizing  the  posterior  wall  of  the  cyst  with 
a  hand  passed  into  the  interior,  to  evert  it  and  afterwards  separate  the  ad- 
hesions. Pressure  or  the  ligature  will  arrest  any  bleeding,  or  the  cautery 
may  be  applied.  If  the  bleeding  is  intractable,  a  good  plan  is  to  pinch 
up  the  abdominal  walls  at  the  bleeding  part  and  pass  a  long,  straight 


AFFECTIONS    OF    THE    FALLOPIAN    TCBES    AND    OVARIES.        2,'W 

needle  through  this  fold,  so  as  to  keep  the  Heeding  peritoneal  surfaces 
in  apposition. 

(b.)  "When  the  adhesions  are  long,  they  may  be  ligatured  at  two  points 
close  to  the  cyst  and  divided  between  these. 

When  adhesions  to  the  bladder  are  present  great  care  must  be  taken, 
as,  in  separating  them,  the  bladder  maybe  torn  into.  If  this  happens, 
the  tear  should  be  stitched  with  tine  catgut,  and  a  catheter  kept  in  for 
some  days.  (  Vide  under  vesico-vaginal  fistula.)  "When  adhesions  are  in- 
separable, the  adherent  portion  of  the  cyst  may  be  ligatured  all  round 
with  silk  and  then  cut  beyond  the  ligatures  ;  or  it  may  be  simply  cut  all 
round  the  adherent  portion,  and  the  edges  then  cauterized. 

For  reflecting  light  into  the  pelvis  or  other  deep  parts,  an  ophthalmo- 
scopic  mirror  is  invaluable. 

G.  The  Peritoneal  Toilette. — This  term  is  a  convenient  one  used  by  Ger- 
man operators  to  indicate  the  rleanxiiif/  of  flv  peri/n/in/D).  It  must  be 
laid  down  as  a  cardinal  principle  in  abdominal  section  that  no  serum  or 
blood  is  to  be  left  in  the  abdomen.  The  peritoneum  should  be  thoroughly 
dry,  and  no  oozing  points  are  to  be  left.  The  importance  of  the  toilette 
cannot  be  too  strongly  insisted  on.  Keith  of  Edinburgh,  whose  success 
in  ovariotomy  is  unrivalled,  takes  the  greatest  care  in  this  matter  and 
attributes  his  success  to  it.  Sims  indeed  says,  "  But  I  think  now  that  it 
matters  very  little  what  we  do  with  the  pedicle,  whether  we  use  the  clamp, 
the  cautery,  or  the  ligature,  provided  we  take  every  care  against  the  exu- 
dation of  bloody  serum  into  the  peritoneal  cavity  after  the  closure  of  the 
abdominal  wound."' 

7.  Closure  of  the   Abdominal    Wound. — This    is   done  as  described    in 
Battey's  operation  (p.  '2()(>). 

8.  Drainay. — As  to  drainage,  the  rule  is  that  none  is  needed  in  simple 
cases;  in  cases  of  many  adhesions,  however,  a  glass  drainage  tube  should 
be  passed  in  at  the  lower  angle  of  the  wound   and  down   into  the  pelvis. 
This    rule   may  seem  to  the  student  to    clash  with  the  invaluable  prinrij'le 
that  every  wound  from  which  there;  will  be  discharge  ou^hl  to  be   drained. 
In  ovariotomy,  however,  the  peritoneum  is  an  absorbent  sac.  and  the   dis- 
charge, after  a  simple  operation,  is  absorbed   Ivfnre  it  hn.<  //;/   •  t«  /  ".'/<_/// 
(Lister).      In  complicated    cases,   this  drainage  by   absorption    is    insuffi- 
cient ;  it  becomes  also  dangerous  from  the  amount   of  serum    thrown  our, 
and  the  risk  of  its  putrefying.      External  dratmiiji'   is.  in   such   cases,  im- 
perative. 


234  MANUAL    OF    GYNECOLOGT. 

9.  Dressing  of  the  Wound. — This  should  be  as  follows  :  a  piece  of  pro- 
tective silk  over  the  wound,  over  this  two  ply  of  carbolic  gauze  wrung  out 
of  1-40  lotion,  then  an  eight-ply  dressing  of  dry  gauze  with  mackintosh, 
and  finally  padding  of  salicylic  wool ;  all  is  secured  by  a  broad  flannel 
bandage.     If  the  pulse  and  temperature  do  not  rise  and  there  is  no  un- 
easiness, this  may  be  left  untouched — in  simple  cases — for  eight  or  nine 
days.     If  there  is  discharge,  the  dressing  should  be  changed  when  it  soaks 
through. 

10.  After-treatment :  Treatment  of  Complications. — Morphiamay  be  given 
hypodermically,  but  only  when  necessary  (vide  p.  179).     Little  food  is 
allowed  for  the  first  thirty-six  hours.     Hot  water  should  be  given  ad 
libitum,  as  it  helps  flatus.     At  the  end  of  this  time,  milk  and  beef-tea  are 
added;    An  enema  may  be  administered  on  the  third  or  fourth  day. 

Complications  may  be — Secondary  hemorrhage  ; 
High  temperature ; 
Septicaemia. 

Secondary  hemorrhage,  if  from  the  pedicle  or  adhesions,  must  be 
treated  by  the  reopening  of  the  wound  and  application  of  ligatures. 

For  high  temperatures,  the  ice-cap  is  good.  The  Americans  recom- 
mend the  more  wholesale  method  of  reduction  of  temperature  by  Kibbee's 
ice-cot.  Krohne  &  Seseman  of  London  supply  very  convenient  ice-caps 
made  of  block-tin  pipe.  Quinine  in  fifteen-grain  doses  tried.  It  is  prob- 
able that  some  high  temperatures,  recorded  by  ovariotomists,  have  been 
due  to  the  absorption  by  the  peritoneum  of  carbolic  acid  used  in  Lis- 
terism. 

In  cases  of  septicaemia  with  peritonitis  where,  drainage  has  been  em- 
ployed, the  peritoneal  cavity  should  be  washed  with  very  weak  carbolic 
lotion  whenever  there  seems  to  be  any  tension  or  accumulation  of  putrid 
fluid  ;  the  abdominal  incision  may  require  to  be  re-opened  for  this  pur- 
pose. The  condition  should  be  further  treated  by  iron  and  stimulants  as 
needed.  (Vide  treatment  of  pelvic  peritonitis.) 

THE   RELATION   OF   LISTERISM   TO   OVARIOTOMY. 

The  Listeiian  method  of  treating  wounds  is  based  on  the  now  generally 
accepted  theory  that  the  germ-laden  air,  coming  in  contact  with  a  wound, 
leads  to  putrefactive  changes  which  may  end  in  septicaemia.  Lister  found 
carbolic  acid  destructive  to  the  activity  of  these  germs  ;  and,  consequently, 


AFFECTIONS    OF    THE    FALLOPIAN    TUBES    AND    OVARIES.       235 

Listerism  requires  that  the  air  in  contact  \vith  the  wound  and  all  else  that 
touches  it,  must  be  purified  either  with  the  spray  or  lotion.  Listerism  is 
in  no  sense  a  treatment  of  wounds,  but  is  a  treatment  of  wound-surround- 
ings. The  application  of  carbolic  lotion  to  a  wound  is  a  necessary  evil,  as 
carbolic  acid  is  an  irritant  and  may  be  absorbed.  In  the  cases  treated  by 
the  surgeon,  Listerism  is  of  the  greatest  value  ;  and,  with  drainage,  has 
worked  the  most  mighty  revolution  in  surgery.  In  peritoneal  operations, 
however,  its  good  is  marred  by  the  fact  that  the  peritoneum  absorbs  the 
carbolic  lotion,  and  thus  its  surface  is  irritated  and  often  toxic  effects 
ensue.  Keith,  Tait,  and  Bantock  have  therefore  abandoned  Listerism  in 
abdominal  surgery  ;  but  Wells  and  Thornton  still  carry  it  strictly  out.  It 
is  evident  that  ovariotomists  must  find  some  method  which,  while  locally 
purifying  the  air,  will  yet  be  innocuous  to  the  wound  surface. 

Practically  most  ovariotomists  at  present  trust  to  modified  Listerism, 
and  to  drainage  when  necessary.  All  Listerian  precautions  should  be 
used  except  the  spray. 

OVAKIOTOMY   BY  ENUCLEATION. 

This  is  a  method  of  ovariotomy  introduced  by  Miner  of  Buffalo.  Ac- 
cording to  him  the  pedicle  divides  into  three  or  four  bands  containing 
blood-vessels  gradually  diminishing  in  the  peritoneal  investment  of  the 
cyst.  The  peritoneal  covering  of  the  cyst  can  be  slit  open  and  can  be 
readily  separated  by  the  finger.  The  vessels  in  the  tissue  between  the 
peritoneum  and  cyst  are  capillary  and  do  not  bleed.  In  this  way  the 
tumour  is  enucleated,  and  the  artificial  stalk — i.e.,  peritoneum  and  pedicle 
— of  tumour  either  left  or  treated  by  ligature,  cautery,  or  clamp.  This 
method  is  good  when  the  tumour  is  irremovable  by  adhesions. 

OVARIOTOMY   WHEN   PREGNANCY  IS  PRESENT. 

Although  pregnancy  coexists  with  a  large  ovarian  tumour,  ovariotomy 
should  still  be  performed.  In  the  paper  of  Spencer  Wells  quoted  he  gives 
a  table  of  nine  cases  where  the  pregnancy  varied  from  the  third  to  the 
seventh  month,  with  the  following  results.  Only  one  mother  died :  the 
pregnancy  went  on  to  full  time  in  five  of  the  cases  ;  in  three  the  child  was 
expelled  prematurely,  and  in  one  the  child  was  removed  at  the  same  time. 
The  question  of  the  treatment  of  a  labour  complicated  with  an  ovarian 
tumour  concerns  the  obstetrician  rather  than  the  gynecologist. 


230  MANUAL    OF    GYNECOLOGY. 

CONTRA-INDICATIONS    TO    OVARIOTOMY. 

These  are,  universal  adhesions  and  malignant  disease.  Ordinary  as- 
cites,  kidney  disease,  or  heart  disease  are  not  centra-indications  unless  far 
advanced.  Prognosis  should  be  careful  in  these  cases. 

COURSE    AND   RESULTS    OF   OVARIAN   TUMOURS    WHEN   LEFT   ALONE. 

Adhesions  may  be  set  up  as  the  result  of  chronic  peritonitis  arising 
from  pressure  and  tapping.  Occasionally  the  cyst  bursts,  and  in  the  case 
of  the  ordinary  ovarian  tumour  we  may  get  rapid  death.  When  parovarian 
tumours  burst,  the  fluid  is  unirritating  and  is  absorbed  by  the  peritoneum, 
the  patient  thus  becoming  cured.  Mathews  Duncan  and  others  have  re- 
corded cases  of  burst  ovarian  tumour  rapidly  becoming  fatal. 

Torsion  of  the  pedicle  to  a  slight  extent  is  often  noticed  in  ovarian  tu- 
mours. When  the  torsion  is  so  great  as  to  cut  off  the  blood-supply  from 
the  cyst,  we  get  gangrene  of  the  tumour,  and  in  some  cases  very  serious 
symptoms,  viz.,  peritonitis,  vomiting,  and  severe  abdominal  pains.  Dr. 
Wiltshire,  of  London,  was  the  first  to  operate  for  this  condition,  and  re- 
cently Lawson  Tait  has  operated  successfully  in  three  cases.  His  papers 
should  be  consulted  for  details.  It  is  interesting  to  note  that  the  tumours 
so  rotated  are  usually  right-sided  and  not  necessarily  ovarian.  The  usual 
explanation  of  the  rotation  is  that  it  is  caused  gradually  by  the  focal  con- 
tents passing  down  the  rectum. 

The  course  and  results  of  ovarian  tumours  when  left  alone  can  fortu- 
nately not  now  be  studied.  The  picture  of  ovarian  disease  running  its 
course  unchecked,  so  eloquently  pictured  by  West,  is  happily  now  almost 
unknown. 

"  We  have  symptoms  of  the  same  kind  as  we  see  towards  the  close  of 
every  lingering  disease,  betokening  the  gradual  failure,  first  of  one  power, 
then  of  another ;  the  flickering  of  the  taper,  which,  as  all  can  see,  must 
soon  go  out.  The  appetite  becomes  more  and  more  capricious,  and  at 
last  no  ingenuity  of  culinary  skill  can  tempt  it,  while  digestion  fails  even 
more  rapidly,  and  the  wasting  body  tells  but  too  plainly  how  the  little 
food  nourishes  still  less  and  less.  The  pulse  grows  feebler,  and  th(  j 
strength  diminishes  every  day,  and  one  by  one  each  customary  exertion  is 
abandoned.  At  first  the  efforts  made  for  the  sake  of  the  change  which  the 
sick  so  crave  for  are  given  up  ;  then  those  for  cleanliness  ;  and  lastly,  those 
for  comfort — till  at  length  one  position  is  maintained  all  day  long  in  spite 


AFFECTIONS    OF    THE    FALLOPIAN    TUBES    AND    OVAUIES.          237 

of  the  cracking  of  the  tender  skin,  it  sufficing  for  the  patient  that  respira- 
tion can  go  on  quietly,  and  she  can  sutler  undisturbed.  AYeariness  drives 
away  sleep,  or  sleep  brings  no  refreshing.  The  mind  alone,  amid  the  gen- 
eral decay,  remains  undisturbed  ;  but  it  is  not  cheered  by  those  illusory 
hopes  which  gild,  though  with  a  false  brightness,  the  decline  of  the  con- 
sumptive ;  for  step  by  step  death  is  felt  to  be  advancing  ;  the  patient 
watches  his  approaches  as  keenly  as  we,  often  with  acuter  perception  of 
his  nearness.  AVe  come  to  the  sick  chamber  day  by  day  to  be  idle  specta- 
tors of  a  sad  ceremony,  and  leave  it  humbled  by  the  consciousness  of  the 
narrow  limits  which  circumscribe  the  resources  of  our  art."  (Quoted  by 
Spencer  Wells.) 

At  present,  ovariotomy  is  one  of  the  most  successful  of  operations. 
Most  ovariotomists  have  now  a  mortality  of  about  1I3  to  15  per  cent.,  while 
in  the  hands  of  Keith  of  Edinburgh  it  has  sunk  to  10  per  cent.  Keith  in- 
deed has  had  7G  consecutive  cases  without  a  death. 


SECTION  V. 

AFFECTIONS  OF   THE  UTERUS. 

THERE  are  three  periods  during  which  morbid  conditions  of  the  uterus 
arise. 

1.  The   period   of  evolution   or  development — from   the  ovum  up  to 
puberty.      During  this  stage  they  appear  as  anomalies  in  development   in 
utero  or  during  childhood.      They  produce  no  marked   symptoms,  but   a 
recognition  of  their  existence  is  important  as  regards  the  future  history 
of  the  patient. 

2.  The  period  of  physiological  activity — from  puberty  to  the  meno- 
pause.    During  this  stage  there  occur  in  the  uterus  the  morbid  processes 
of   acute   and   chronic   inflammation,   and   of    new   formation   or  tumour 
growth  ;  on  account  of  its  mobility,  the    uterus  is  also  liable   to  various 
forms  of  displacement.     These  pathological  processes  give  rise  to  symp- 
toms of  themselves,  and  also  from  their  effect  on   the   normal   functions  <>t' 
the  uterus     menstruation,   conception,   and   pregnancy.      .During  parturi- 
tion the  cervix  uteri   is  frequently  lacerated,  and  this  constitutes  an   im 
portant  pathological  condition. 

3.  The    period   of   senile   involution    or   retrogressive    development 
from  the  menopause  to  death.      The    term  involution  is  generally  used   in 
the  restricted  sense  of  the  process  which   occurs  after  childbirth,  but  it  is 
the  only  one  which  conveniently  expresses  the  retrogressive   changes  after 
physiological  activity  has  ceased.     During  this  stage  tin-  most  important 
pathological  process  is  that  of  malignant  new  formation. 

Accordingly  this  section  of  the  subject  falls  into  chapters  as  follows  : 

CHAPTEK  XXITI.   Malformations  of  the  Fterus. 

XXIV.  Atresia  and  Stenosis  of  the  Cervix  Fieri. 
"  XXV.   Atrophy  of  the  Cervix  and  Fterus  ;  Superinvolution. 

"         XXVI.   Hypertrophy  of  the  Cervix  ;  Amputation. 


240  MANUAL    OF    GYJSTECOLOGY. 

CHAPTER     XXVH  Laceration  of  the  Cervix. 

XXVHL  Chronic  Cervical  Catarrh.     . 

XXIX.  Endometritis. 

"  XXX.  Metritis,  Acute  and  Chronic  ;  Subin volution. 

"          XXXI.  Displacements  of  the  Uterus  ;  Anteflexion  ;  Antever- 

sion  ;  Retroversion  ;  Retroflexion. 
XXXH.  Inversion  of  the  Uterus. 

XXXIII.  Fibroid  Tumour  of  the  Uterus  ;  Pathology  and  Eti- 
ology. 

"        XXXIV.  Fibroid  Tumour  of  the  Uterus  ;  Symptoms  and  Di- 
agnosis. 

XXXV.  Fibroid  Tumour  of  the  Uterus  ;  Treatment. 
XXXVI.  Fibrocystic  Tumour  of  the  Uterus. 
"       XXXVII.  Polypi  of  the  Uterus. 

"     XXXVIH.  Carcinoma  Uteri  (of  Cervix) ;   Pathology  and  Eti- 
ology. 

"        XXXIX.  Carcinoma  Uteri  (of  Cervix)  ;  Symptoms  and  Diag- 
nosis. 

"  XL.  Carcinoma  Uteri  (of  Cervix)  ;  Treatment. 

"  XLI.  Carcinoma  Uteri  (of  Body). 

"  XLII.  Sarcoma  Uteri. 


CHAPTER  XXIII. 
MALFORMATIONS  OF  THE  UTERUS. 

LITERATURE. 

Barnes — Op.  cit.,  p.  462.  Churchill — Obst.  Journal  of  Great  Britain,  1873,  p.  256. 
Kussmaid — Von  dem  Mangel,  der  Verkiimmerung  und  Verdoppelung  der  Gebar- 
mutfcer,  etc. :  Wurzburg,  1859.  Mayerlwfcr — Die  Entwickelungsfehler  der  Gebar- 
mutter :  Billroth's  Handbuch  fiir  Frauenkrankheiten,  Stuttgart,  1878.  Schroeder 
—Op.  cit.,  S.  33.— Simpson,  A.  R.— Ed.  Med.  Jour.,  1863,  p.  957.  Turner— 
Edin.  Med.  Jour.,  June,  1865,  and  May,  1866.  The  standard  work  is  that  of 
Kussmaul.  The  literature  is  given  most  fully  by  Mayerhofer. 

WHAT  is  usually  described  as  "  a  malformation  "  is  really  a  non-formation 
of  one  part,  involving  a  relative  disproportion.  Of  this  we  have  an 
illustration  in  the  uterus.  The  one-horned  uterus  is  not  a  "  malforma- 
tion," if  by  this  term  we  mean  that  the  part  which  is  present  is  malde- 
veloped  ;  the  condition  is  a  result  of  the  new-formation  of  the  other  horn 
and  intervening  fundus.  It  is  misleading  also  to  speak  of  a  "double 
uterus  ;"  the  condition  thus  desciibed  is  really  a  halved  uterus,  in  which 
the  halves  have  not  united  into  the  whole.  The  word,  as  used,  therefore 
means  an  incomplete  result,  not  a  defective  process.  J/a/-development  is 
a  contradiction  in  terms,  there  can  only  be  arrested  developments. 

Malformations  must  be  studied  in  connection  with  the  normal  devel- 
opment of  the  organ.  In  this  way  they  become  at  once  intelligible. 
There  are  two  processes  in  the  progression  of  an  organ  to  its  mature 
form — development  and  growth.  There  are  therefore  two  causes  which 
together  operate  in  producing  malformations — arrested  development  and 
arrested  growth.  The  period  of  development  of  the  uterus,  by  which  we 
mean  formation  of  parts,  extends  up  to  the  twentieth  week  ;  the  period 
of  growth  is  much  longer,  and  extends  to  the  twentieth  year  (Arnold). 

The  student  should  not  pass  over  this  section  of  the  subject  as  of 
little  importance.  To  the  practical  man,  malformations  seem  of  little 
value  because  he  has  no  power  of  modifying  the  result.  To  the  scientific 
VOL.  I.— 16 


242 


MANUAL    OF    GYKECOLOGY. 


man  they  are,  however,  of  the  greatest  interest  as  furnishing  him  with 
permanent  impressions  of  the  transient  states  of  development ;  they  are 
development  caught  in  the  act  and  fixed  permanently  for  after-investiga- 
tion. In  this  chapter  we  recommend  the  student  to  read  Etiology  before 
Pathology. 


PATHOLOGY. 


Complete  absence  of  the  uterus  is  an  extremely  rare  occurrence,  and 
cannot  be  demonstrated  except  on  post-mortem  examination.     It  has  been 


Fig.  137. 

Rudimentary  uterus  (Veit).    Sa,  sacrum ;  f/i  solid  rudiment  of  utertis ;  A,  rudimentary  horn  ;  B,  bladder  ; 
O,  ovary ;  T,  Fallopian  tube ;  r,  round  ligament. 

described  only  in  cases  of  fostal  monstrosities.     A  rudimentary  condition 
sometimes  occurs  ;  in  this  the  uterus  is  represented  by,  a  band  of  muscn- 


Tig.  138. 

The  same  in  its  relation  to  the  pelvic  organs.     J7,  rudiment  of  uterus  on  the  posterior  wall  of  bladder. 
The  peritoneum  forms  one  pouch  between  bladder  and  rectum  (Schroeder). 

lar  fibre  and  connective  tissue  on  the  posterior  wall  of  the  bladder  (Fig. 
137),  and  the  peritoneum  forms  a  single  pouch  between  the  bladder  and 
the  rectum  (Fig.  138). 


AFFECTIONS    OF    THE    UTKUUS. 

Ill  the  uteru*  bipartitn*  (Fig.  139),  rudimentary  horns  are  present  and 
are  solid  or  hollow.  The  cervix  is  represented  by  a  iibrous  band  which 
connects  the  horns  with  one  another  and  with  a  rudimentary  vagina.  The 


Uterus  bipartitus  (Rokitansky).     I',  vaprina:   r.  uterus  ;  ft.  nulimei.tarj-  horn  :   0,  o\ary:   7",  tube  ;  r,  ror.nd 


ovaries  are  sometimes  well  developed  so  that  ovulation  takes  place.     The 
breasts  and  external  genitals  may  be  fully  formed. 

Tin;  iifi'rit*  >inirt>7'iii.ff  (FiiT-  140)  may  exist  with  or  without  a  rudimen- 
tary second  horn.  The  vaginal  portion  of  the  cervix  is  small  :  the  palma- 
plieata'  within  the  cervical  canal  are  most  marked  towards  the  non-devel- 
oped side.  The  body  of  the  uterus  is  of  disproportionate  length  and 


unirorr.is  (SrhrncdoiM.      1:.  r;u"l;l  <-:j].-  :    /..lift    vdr.     'I'};*-   l.-ft    h-rn    f  '  i   i-   well 


i.      Otln-r  li'tter-  a-  in  \<w<  dinq  din-ra 


curves  towards  one  side.  The  fundu^.  by  winch  \\c  undnxtand  tin1  I'ulK 
developed  horn,  is  small  and  tapi'vinu'  ;  it  lia-^  only  one  Fallopnn  tul-e 
and  ovary  connectc-d  with  it.  On  tlie  convex  side  of  the  some\\h;it 
curvc-d  body,  is  tlie  representative  of  the  other  horn.  v\hich  i^  <  iiher  -.oli.l 
or  hollow;  it  U  connected  with  the  developed  one  by  libn,n->  ti-^ue, 


244  MANUAL    OF    GYNECOLOGIC 

which  may  or  may  not  form  a  pervious  canal.  Connected  with  this  rudi- 
mentary horn  are  the  Fallopian  tube  and  ovary  of  the  same  side,  which 
are  sometimes  perfectly  developed.  In  examining  preparations  of  this 
and  other  uterine  malformations,  it  is  sometimes  difficult  to  determine 
what  is  rudimentary  horn  and  what  is  Fallopian  tube.  Here  development 
furnishes  us  with  a  guide.  The  insertion  of  the  round  ligament  indicates 
the  point  up  to  which  the  ducts  of  Muller  are  to  be  formed  first  into  ute- 
rine horn  and  then  into  fundus  uteri.  Accordingly,  on  examining  such 
preparations  we  determine  the  point  of  attachment  of  the  round  ligament  ; 
all  below  this  is  uterine  horn,  all  above  it  is  Fallopian  tube.  Associated 
with  this  malformation  we  sometimes  find  absence  or  rudimentary  condi- 
tion of  the  kidney  of  the  same  side,  since  the  development  of  the  renal  is 
closely  connected  with  that  of  the  generative  system. 

In  the  uterus  didelphys  the  two  halves  of  the  uterus  remain  separate 
throughout  their  course.  It  is  a  very  rare  condition  in  the  living  adult 
female,  and  has  been  usually  described  in  foetal  monstrosities.  The  vagina 
may  be  absent,  single,  or  double. 

By  uterus  bicornis  we  understand  that  the  separation  into  two  horns  is 


Pig.  141. 
Uterus  bicornis  nnicollis  (Schroeder).  r,  round  ligament. 

distinctly  visible  externally.  Of  this  there  are  various  degrees,  from  a 
mere  depression  at  the  middle  of  the  fundus  to  a  well-marked  bifurcation 
which  rarely  extends  lower  than  the  os  internum  ;  the  farther  down  the 
separation  extends,  the  more  obtuse  is  the  angle  between  the  divergent 
horns.  In  addition  to  this  external  division,  the  separation  is  usually 
carried  farther  down  by  an  internal  septum  which  may  extend  to  the  os 
externum. 

In  the  uterus  septus  (Fig.  142)  there  is  no  external  indication  of  the  in- 


AFFECTIONS    OF   THE    UTERUS. 


245 


ternal  division.  The  uterus  is  divided  by  a  septum  beginning  at  the 
fundus  uteri  and  extending  downwards  for  varying  distances,  sometimes 
as  far  as  the  os  externum.  It  is  otherwise  normal. 


y 

Pig.  143. 

Uterus  septns  in  vertical  transverse  section  (Kussmaul).  If  (Uterus},  placed  on  septnm  which  diyides 
cavity  into  two  lateral  portions ;  T,  Fallopian  tubes ;  \\  vagina  divided  into  lateral  cavities  by  prolongation 
of  septum  downwards. 

The  infantile  uterus  (Fig.  143)  is  characterized  by  shortness  of  body 
and  disproportionate  length  of  cervix  ;  in  fact  the  relative  lengths  of  body 
and  cervix  remain  the  same  as  at  birth,  from  which  the  name  "  infantile  " 


Fig.  143. 

Infantile  uterus  (Schroeder). 

is  derived.  The  cervix  (If  inch  long)  is  two  or  even  three  times  the 
length  of  the  body  (f  inch  to  f  inch).  The  whole  uterus  is  smaller  than 
the  normal.  The  walls  (especially  those  of  the  body)  are  thin  and  the 
cavity  is  small. 

The  term  congenital  atrophy  is  applied  to  cases  in  which  the  proper- 


.246  MANUAL    OF    GYNECOLOGY. 

tions  of  body  and  cervix  are  of  the  normal  virgin  type,  while  the  organ  as 
a  whole  is  atrophied  (Fig.  144).  An  excess  of  connective  tissue  is  present 
in  the  walls,  which  makes  their  consistence  firmer.  This  malformation 


Tig.  144, 

Primary  atrophy  of  the  uterus  (Virchow). 

occurs  in  scrofulous  and  chlorotic  patients,  and  is  often  associated  with 
hysteria  and  epilepsy. 

ETIOLOGY   AND   CLASSIFICATION. 

Malformations  differ  according  to  the  period  at  which  development 
and  growth  are  arrested,  and  the  extent  to  which  they  are  interfered  with. 
There  are  five  periods  in  development  and  growth  (Fiirst),  which  can  be 
easily  remembered  when  we  bear  in  mind  the  division  of  the  period  of 
intra-uterine  life  into  ten  lunar  months.  In  the  first  period,  which  ex- 
tends over  the  first  and  second  lunar  months  (from  fertilization  to  the 
eighth  week),  the  septum  between  the  adjacent  ducts  of  Miiller  is  as  yet 
unbroken.  By  the  6nd  of  the  second  period,  which  corresponds  to  the 
third  month  (i.e.,  eighth  to  twelfth  week),  the  septum  has  entirely  dis- 
appeared ;  but  the  upper  portions  of  the  ducts  remain  distinctly  separate, 
forming  the  horns  of  the  uterus  and  the  Fallopian  tubes.  During  the 
third  period,  fourth  and.  fifth  months,  the  angle  between  the  uterine  horns 
disappears  so  that  the  base  of  the  uterus  becomes  flat.  In  the  fourth 
period,  lost  five  months,  the  flattened  end  of  the  uterus,  between  the 
Fallopian  tubes,  becomes  arched  through  the  development  of  the  fundus. 
The  fifth  period  extends  from  birth  to  puberty.  During  this  period  no 
important  change  takes  place  till,  at  puberty,  the  uterus  passes  from  the 


AFFECTIONS    OF    THE    TTEUUS.  247 

infantile  to  the  virgin  form.     It  does  not,  however,  cease  to  grow  till  the 
twentieth  year. 

We  are  not  yet  in  a  position  to  refer  each  malformation  in  detail  to  its 
proper  period  ;  but  the  more  perfectly  we  aiv  able  to  do  this  the  more 
satisfactory  will  our  classification  be.  At  present  we  separate  the  tirst  four 
periods  from  the  fifth,  and  speak  of  the  period  of  f.etal  life  in  contra-dis- 
tinction  to  the  period  of  childhood.  This  forms  the  basis  of  our  classifica- 
tion. 

1.  MALFORMATIONS  ARISING  DURING  FU-:TAL  LIIT.. — Of  these  there  are  the  fol- 
lowing :  complete  absence  ov  rudimentary  condition  of  the  uterus  ;  the  nd-rii* 
/t/l)'ir'ifi(tf,  produced  by  a  development  of  only  the  upper  parts  of  the  ducts 
of  Midler  into  rudimentary  horns  of  the  uterus  and  Fallopian  tubes  ;  the 
iiti'ms  iin/foi'ni*,  due  to  the  development  of  onlv  one  duct  ;  the  ///c/v/.s- 
didclpltij*.  due  to  the  development  of  the  ducts  separately,  without  coales- 
cence ;  the  iiliTHft  bicrtrnit*,  iu  which  the  ducts  coalesce  below,  and  the 
horns  remain  ununited  by  a  fundiis  above  ;  the  ///»•/•".»•  .-•>•/ i/u.--.  in  which  the 
coalescence  of  the  ducts  and  development  of  the  fundiis  take  place,  so  that 
the  uterus  appears  normal  externally  while  internally  the  septum  has  per- 
sisted, 

'2.  MALFORMATIONS  AKISINO  i>ruiN<;  CHILDHOOD. — Of  these  there  are  the  fol- 
lowing :  the  iifi'i'i/.^  infantile,  in  which  the  uterus  does  not  undergo  th«>  de- 
velopment which  should  take  place  at  puberty  but  remains  of  the  same  type 
as  it  was  at  birth  ;  congenital  atr<>]>ii>/  of  the  uterus,  in  which  it  assumes  the 
virgin  type,  but  the  organ  as  a  whole  is  atrophied. 


SYMPTOMS. 


The  symptoms  of  malformation  consist  in  an  iinpainncnt  off  unction, 
and  hence  do  not  appear  until  puberty. 

In  the  external  appearance  of  the  patient  there  is  not  necessarily  any- 
thing to  attract  attention.  The  figure,  features,  temperament,  and  voice 
are  of  the  feminine  type,  even  though  the  uterus  is  not  developed.  The 
mamm;e  may  bo  fully  formed.  The  development  of  the  external  genitals 
is  independent  of  the  development  of  the  internal  organs. 

Complete  absence  and  rudimentary  condition  of  the  uterus  may  give 
rise  to  no  local  symptoms,  except  the  non-appearance  of  menstrual  n  m.  It 
the  ovaries  are  developed,  ovulation  with  associated  monthly  disturbance 
is  present  and  the  accumulation  of  menstrual  blood  in  a  rudimentary  horn 


248 


MANUAL    OF    GYNECOLOGY. 


may  call  for  operative  measures  to  form  a  channel  for  its  escape.  Even  on 
entering  married  life  the  condition  need  not  necessarily  attract  attention  ; 
if  the  vagina  be  not  well  developed,  the  urethra  becomes  dilated  so  as  to 
take  its  place. 

In  the  uterus  unicornis,  menstruation,  conception,  and  pregnancy  may 


^  *2  "9  a 

1  §3 
£  T  * 
~-  2 
ST  -«  a 


5   ? 


**       <U       (y 

'  *^3    — « 
C    "oc     O 

IIs 

I  2S 

*•  &  ^ 

•S  5  ^ 
H  5  •? 

c  S 


^J  *~> 

S  S 


• 


»H    S  -S  .3 

ti-  SS^ 

tS  H    ,,    » 


ro    *? 
g    a.    J3 

iii 


5  1 

tC      *l> 
M      »-• 


b  00 

fl)  -U 

I  § 

•g  | 

E  = 


£  I 

•fi  § 


go  on  undisturbed  in  the  developed  horn.  It  is  the  imperfectly  developed 
horn  which  gives  rise  to  the  symptoms — the  result  of  the  retention  of  men- 
strual blood  and  of  the  products  of  conception.  If  the  mucous  membrane 


AFFECTIONS    OF    THE    UTERUS. 


249 


of  this  horn  discharge  blood  periodically  and  there  be  no  communication 
with  the  uterus  to  allow  of  escape,  the  blood  collects  and  produces  a  dis- 
tended sac.  It  is  of  great  interest  to  note  that  we  may  have  a  fertilized 
ovum  growing  in  the  isolated  horn  ;  we  have  not  space  here  to  discuss  how 
this  interesting  condition  is  produced  (Fig.  145).  Uterus  bicornis  and 
uterus  septus  produce  no  symptoms,  unless  one-half  of  the  septate  uterus 
does  not  open  into  the  cervical  canal— in  which  case  h;ematometra  occurs 
at  puberty  (i:  Chap.  XLHI.).  The  statement  that  the  patient  menstruates 
regularly  throws  the  practitioner  oil'  his  guard.  He  should  remember  that 


Uterus  Keptu=   (posterior   view)  from  a  woimm  -.vim  diod  in  the  puerporium  (Truvoilhier).     Thr  u'<  rinr 


cavity  is  divided  by  ;i  septum  wt.ich 


xu-rnuin.     The  left  half   , 


and  contained  the  fn-tus.     The  ri.Lrht  h.-ilf  (2j  was  eiupt\ 


the  menstrual  blood  rna>/  /loir  u.rtdixlnrfH'd  from  our  half  nf  thf  ut<Tn*  ir/ii/i- 
it  is  accumulating  in  tin;  of  her.  In  both  of  these  forms  \ve  have  two  possi- 
ble seats  for  a  growing  ovum  /Fig.  14(>),  and  thus  we  can  explain  some 
cases  of  superfootation  ;  after  a  fu'tus  lias  begun  to  develop  in  one  half  of 
the  uterus,  a  second  ovum  becomes  fertilized  in  the  other  and  reaches 
maturity  at  a  later  period  than  the  first.  We  may  thus  also  explain  some 
cases  in  which  menstruation  occurs  during  the  early  months  of  gestation. 
The  uterus  infantilis  and  the  con<renitallv  small  uterus  are  characteri/ed 


250  MANUAL    OF    GYNECOLOGY. 

by  the  absence  of  menstruation  and  the  constitutional  nervous  disturb- 
ance which  is  usually  associated  with  them. 


DIAGNOSIS. 

Complete  absence  of  the  uterus  cannot  be  diagnosed  with  certainty  in 
the  living  subject.  A  rudimentary  condition  may  be  present,  and  yet  not 
be  detected  on  the  most  careful  examination.  To  examine  cases  in  which 
this  condition  is  suspected,  we  first  pass  a  sound  into  the  bladder  and  then 
with  one  or  two  fingers  of  the  right  hand  in  the  rectum  palpate  the  tissues 
which  lie  between  the  sound  and  the  fingers.  It  is  evident  that  in  such  a 
condition  as  is  represented  in  Fig.  138  the  rudiment  of  the  uterus  may 
escape  observation,  or  be  considered  as  a  thickening  of  the  posterior  wall 
of  the  bladder.  We  now  remove  the  sound  from  the  bladder,  as  it  only 
reaches  to  a  limited  height  in  the  pelvis,  and  with  the  left  hand  on  the 
abdomen  make  a  careful  recto-abdominal  examination.  To  do  this  last 
satisfactorily,  we  anaesthetise  the  patient.  If  we  feel  two  bodies  laterally 
without  any  distinct  body  between,  it  is  impossible  to  say  whether  these 
are  rudimentary  horns  or  ovaries. 

The  diagnosis  of  the  one-horned  uterus  is  not  easy.  The  points  to 
rely  on  are  the  following :  the  fundus  turns  to  one  side  of  the  pelvis,  is 
tapering,  and  has  only  one  ovary  connected  with  it.  The  rudimentary 
horn  and  the  other  ovary  lie  removed  from  it. 

The  uterus  didelphys  is  extremely  rare.  A  groove  on  the  external 
surface  of  the  uterus  separating  it  into  lateral  halves,  so  that  sounds  could 
be  passed  into  the  separate  cavities  without  coming  in  contact,  indicates 
this  condition. 

The  uterus  bicornis  is  a  comparatively  frequent  condition,  and  if  well 
marked  is  easily  recognized.  Unusual  breadth  of  the  fundus  with  a 
slight  depression  in  the  centre,  points  to  a  minor  degree  of  this  deformity. 

The  uterus  septus  is  easily  diagnosed  if  the  septum  extend  as  far  as 
the  os  externum,  so  as  to  be  within  reach  of  the  examining  finger.  If  the 
septum  does  not  extend  so  far,  the  condition  may  not  be  detected  as  there 
is  no  change  in  the  external  form  to  direct  attention  to  the  internal  mal- 
formation. The  sound  may  pass  with  equal  ease  into  either  cavity  or 
always  into  the  same,  and  thus  furnish  no  indication.  In  a  case  that  came 
under  our  own  observation  the  patient  was  examined  frequently  during 
life,  bimanually  and  with  the  sound,  and  the  uterus  pronounced  normal. 


AFFECTIONS  OF  THE  UTERUS.  251 

At  the  post-mortem,  the  external  appearance  of  the  uterus  was  normal ; 
it  was  only  on  cutting  into  it  that  it  was  observed  that  the  cavity  was 
divided  into  two  portions  by  a  septum  which  extended  to  the  os  internum. 
The  uterus  iufantilis  and  the  congenitally  atrophic  uterus  are  recog- 
nized by  the  smallness  of  the  uterus.  This  is  most  distinctly  made  out 
with  the  finger  in  the  rectum,  the  uterus  being  at  the  same  time  drawn 
down  and  fixed  with  the  volsella.  The  well-developed  vaginal  portion  and 
the  unusual  length  of  the  cervix  as  felt  per  rectum  enable  us  to  diagnose 
the  infantile  from  the  congenitally  small  uterus. 

PROGNOSIS. 

In  prognosis  we  must  keep  in  view  the  possibility  of  ovulation  with 
menstrual  molimina,  the  secretion  of  menstrual  blood  and  its  accumula- 
tion in  a  closed  cavity,  the  probability  of  conception  and  of  gestation  in 
an  isolated  horn.  The  most  difficult  cases  are  those  in  which  the  practi- 
tioner has  to  decide  whether  marriage  is  justifiable  or  not. 

TREATMENT. 

Malformations  of  the  uterus  lie  beyond  the  range  of  treatment,  except 
when  they  give  rise  to  retention  of  menstrual  blood  or  of  the  products  of 
conception.  The  treatment  of  these  conditions  will  be  considered  under 
Atresia  of  the  Vagina  (see  Section  VL),  and  Extra-uterine  Gestation  (see 
Section  IX.). 


CHAPTER   XXIY. 
ATEESIA  AND  STENOSIS  OF  THE  CERVIX  UTERI. 

LITERATURE. 

Barnes  —  Op.  cit.,  p.  245.  OreenJidlgh  —  British  Med.  Jour.,  June,  1878.  Mackintosh  — 
Practice  of  Physic:  London,  1836,  p.  481.  Schroeder—Op.  cit.,  S.  64.  Schultze  — 
Ueber  Indication  und  Methode  der  Dilatation  des  Uterus  :  Wiener  med.  Blatter, 
1879,  Nos.  42,  43,  44,  45.  Simpson,  Sir  J.  T.  —  Op.  cit.,  p.  245.  Sims,  Marion  — 
On  the  Surgical  Treatment  of  Stenosis  of  the  Cervix  Uteri  :  Am.  Gyn.  Trans.  , 
1878,  p.  54.  Smith,  H.—  Obst.  Jour.,  London,  Vol.  V.,  p.  256.  T7iomas—Op. 
cit.,  p.  613. 


DEFINITION.  —  Atresia  (a-rp^o-is,  non-perforation)  is  an  occlusion  of  the  canal. 
Stenosis  is  a  concentric  contraction  of  its  lumen. 

ATRESIA  OF  THE  CERVIX. 

ETIOLOGY   AND   PATHOLOGY.  , 

Atresia  is  rare  as  a  congenital  condition  ;  this  is  due  to  the  presence  of 
a  cap  of  tissue  covering  the  os  uteri.  An  imperforate  condition  of  the 
canal  throughout  its  course  is  seldom,  if  ever,  found. 

It  is  more  frequently  acquired,  and  results  from  the  following  causes  :  — 
Sloughing  and  cicatrisation  after  labour  ; 
Cicatrisation  after  the  application  of  caustics,  and  after  amputation 

of  the  cervix  ; 
Adhesion  of  granulations  in  cervical  catarrh  (after  menopause)  and 

round  the  base  of  tumours. 

The  practical  point  for  the  practitioner  to  remember  is  that  atresia  may 
follow  the  repeated  application  of  caustics  and  amputation  of  the  cervix. 
It  occurs  also  as  part  of  the  physiological  changes  which  take  place  after 
the  menopause.  Twenty-eight  per  cent,  of  women  above  fifty  years  of  age 
have  atresia  of  the  cervix  (Hennig). 

Atresia  of  the  cervix  is  chiefly  of  importance  in  regard  to  the  accumu- 


AFFECTIONS    OK    THE    UTERUS. 

lation  of  menstrual  blood  or  mucus  above  the  obstruction.  It  is  this 
which  produces  the  Symptoms  and  calls  for  Treatment.  It  will  be  better 
to  defer  the  consideration  of  these  till  we  treat  of  Atresia  Vagiiue  (Section 
VI.). 

STENOSIS  OF  THE  CERVIX. 

This  condition  is  described  in  English  and  American  text-books  under 
''Obstructive  Dysmenorrhoaa. ''  Dysmenorrhcra  is,  however,  a  symptom 
common  to  this  and  many  other  pathological  conditions,  each  of  which  is 
considered  under  the  organ  in  which  it  occurs.  Stenosis  of  the  os  exter- 
num  is  a  precise  pathological  condition  which  requires  a  definite  line  of 
treatment. 

PATHOLOGY. 

The  common  seat  of  the  stenosis  is  at  the  ox  <\rt<'rnmn.  It  is  a  dis- 
puted point  whether  there  is  ever  stenosis  (as  we  IKUC  defined  it)  at  the 
os  internum.  Barnes  says  that  when  he  has  found  the  obstruction  ;it  the 
os  internum  it  was  almost  always  due  to  llexion  of  the  uterus.  The  ob- 
struction is.  in  such  a  case,  not  a  true  stenosis  ;  it  might  be  compared  to 
the  kink  produced  on  a  gutta-percha  tube  when  it  is  benf.  Spasmodic 
contraction  of  the  muscular  fibres  surrounding  the  os  internum,  taking 
place  at  the  menstrual  pciiod,  is  adduced  by  some  to  explain  the  symp- 
toms of  dysmenorrhoea. 

In  the  congenital  variety,' the  cervix  is  conical  in  form  (Fig.  11")  and 


of  unusually  firm  consistence.  Sometimes  it  is  hypertropliicil.  the  vaginal 
portion  measuring  as  much  as  two  inches  (IJanies).  The  os  is  snnll.  and 
appears  as  a  pin-hole  on  the  extremity  of  the  cervix.  The  contra-t 
between  this  and  the.  normal  oa  is  well  seen  in  Fig.  11'.'.  Tii>  cervical 
canal  above  the  obstruction  is  often  dilated  into  a  spindle  .^hapi-  1  cavity 
(Fig.  US;. 


254 


MANUAL    OF    GYNECOLCGY. 
ETIOLOGY. 


Like  atresia,  stenosis  of  the  cervix  is  congenital  or  acquired.  The  com- 
monest causes  of  the  acquired  form  are  cicatrisation  after  labour,  after 
amputation  of  the  cervix,  and  after  the  repeated  application  of  strong 


Fig.  148. 

Stenosis  of  os  externnm,  with  dilated  cervical  canal  (Munde).    The  parallel  lines  beside  the  os  show  the 

extent  of  the  bilateral  incision. 

caustics  ;  the  last  is  perhaps  the  most  frequent  cause.     Inflammation  of 
the  mucous  membrane,  resulting  in  adhesions,  also  produces  it. 

SYMPTOMS. 

The  symptoms  primarily  produced  by  the  stenosis  are  dysmenorrhcea, 
sterility,  dyspareunia.  In  addition,  there  is  in  some  cases  menorrhagia. 
If  the  condition  exist  for  a  time,  pelvic  peritonitis  or  ovaritis  may  com- 
plicate the  case. 

The  cause  of  the  dysmenorrhcea  is  evident.  The  menstrual  blood  is 
poured  into  the  cavity  of  the  uterus,  the  contracted  condition  of  the  out- 
let prevents  its  escape,  it  coagulates,  the  coagula  excite  uterine  contrac- 
tions which  are  accompanied  with  pain.  Hence  the  menstrual  blood  is 
usually  discharged  as  clots.  In  the  first  instance,  the  simple  mechanical 
obstruction  is  the  cause  of  the  dysmenorrhcea.  Other  pathological  con- 
ditions, as  endometritis  and  metritis,  arise  secondarily  ;  and  the  monthly 
congestion  of  the  tissues,  thus  diseased,  will  also  produce  pain.  We 
shall  refer  to  this  subject  again  under  Anteflexion  of  the  Uterus. 


AFFECTIONS  OF  TUB  UTEKUS.  255 

The  association  of  sterility  with  a  conical  cervix  and  pin-hole  os  has 
been  for  a  long  time  recognised.  We  are  not  able  to  explain  why  a  nar- 
row os  should  lessen  the  probabilities  of  fertilization,  yet  it  is  a  well-ob- 
served fact  that  it  does  so. 

Sterility  due  to  this  cause  is  amenable  to  treatment,  and  presents  the 
most  satisfactory  cases  which  the  practitioner  has  to  deal  with,  as  by  the 
simple  operation  to  be  presently  described  he  may  remove  the  great  op- 
probrium of  married  life. 

DIAGNOSIS. 

The  history  of  dysmenorrhoea  and  sterility  may  have  already  led  us  to 
suspect  this  condition  ;  but  since  these  symptoms  as  frequently  accom- 
pany anteflexion,  we  have  recourse  to  the  physical  examination. 

The  conical  cervix  projecting  markedly  into  the  vagina  attracts  atten- 


Fig.  149. 
Normal  and  pin-hole  os,  as  seen  In  the  speculum  (Schroeder). 

tion.  On  feeling  for  the  os  uteri,  the  first  impression  is  that  it  is  absent ; 
more  careful  examination  detects  a  slight  depression. 

The  speculum  shows  the  appearance  represented  in  Fig.  149.  The 
normal  os  uteri  is  placed  alongside,  to  be  compared  with  it. 

The  sound  is  passed  with  difficulty  ;  sometimes  a  surgical  probe  is  all 
that  the  orifice  will  admit.  After  it  has  passed  the  os  externum,  the 
instrument  may  enter  a  dilated  cervix  (Fig.  148). 

PBOGNOSIS. 

This  will  depend  on  (1)  the  existence  of  stenosis  of  the  os  extemum 
uncomplicated  by  anteflexion,  (2)  the  absence  of  pelvic  peritonitis  and 
ovaritis.  If  these  conditions  are  fulfilled,  the  prognosis  is  favourable  as 
regards  the  cure  of  the  dysmenorrho3a  and  probably  so  as  regards  the 
cure  of  the  sterility.  As  regards  the  latter,  however,  we  must  remember 
that  there  are  many  other  causes  which  may  .be  operative  and  may  escape 


256  MANUAL    OF    GTNECOLOGY. 

detection.     All  that  we  can  say  to  the  patient  is,  that  by  operative  proce- 
dure we  can  increase  the  probability  of  the  occurrence  of  pregnancy. 

TREATMENT. 

The  methods  of  treatment  are — 

A.  Dilatation, 
JB.  Division. 

Dilatation  of  the  stenosis  is  carried  out  by  passing  graduated  bougies, 
by  sponge  or  laminaria  tents,  by  forcible  dilatation  with  instruments. 
Division  is  effected  by  the  metrotome  or  by  scissors. 

A.  Dilatation. 

Dilatation  by  means  of  graduated  bougies  was  brought  into  prominent 
notice  by  Dr.  Macintosh,  who  employed  straight  metallic  bougies  of  differ- 
ent degrees  of  thickness.  He  passed  first  a  small  one  not  thicker  than  a 
probe,  and  then  larger  ones  till  the  os  was  rendered  quite  patulous. 

Sponge  and  laminaria  tents  have  also  been  largely  used.  The  objection 
to  them,  as  well  as  to  the  dilatation  with  graduated  bougies,  is  that  the 
cure  is  only  temporary.  With  a  laminaria  tent  we  may  dilate  the  stenosis 
so  that  the  finger  easily  passes  it,  but  in  a  few  days  it  will  have  contracted 
to  its  original  size.  The  use  of  tents  is  also  attended  with  the  risks  of 
cellulitis,  peritonitis,  and  even  septicaemia  (see  p.  137). 

forcible  dilatation  is  effected  by  Schultze  of  Jena  with  the  dilator  rep- 
resented at  Fig.  150.  He  dilates  the  cervical  canal  beforehand  with  lami- 


Pig.  150. 

Schultze's  dilator. 

naria  ;  he  then  washes  it  out  with  a  2  per  cent,  solution  of  carbolic  acid, 
as  he  attributes  many  of  the  serious  consequences  of  forcible  dilatation 
and  incision  to  the  absorption  of  the  secretions.  The  dilator  is  now  in- 
troduced, and  the  blades  (which  open  antero-posteriorly)  are  forcibly  sep- 
arated. We  have  had  no  experience  of  this  method  of  treating  stenosis. 
The  dilator  employed  by  Marion  Sims  is  seen  at  Fig.  151. 


AFFECTIONS    OF    THE    UTERUS. 


B.  Division. 


257 


Division  of  the  cervix  with  the  knife  was  introduced  by  Sir  James 
Simpson.  The  instrument  which  he  devised  for  this  purpose  was  the 
metroiome  represented  at  Fig.  152. 

It  is  a  bistoury  cach<§,  with  a  single  blade  sharp  on  the  outer  edge 
which  is  unsheathed  on  compressing  the  handle.  The  screw  on  the  handle 
regulates  the  extent  to  which  the  blade  is  to  be  protruded.  The  instru- 


Fig.  151. 

Marion  Sims'  dilator  (Sims). 

ment  was  passed  in  till  the  point  almost  reached  the  os  internum  ;  it  was 
turned  with  the  blade  to  one  side,  and  then  withdrawn,  the  handle  being 
at  the  same  time  more  and  more  compressed.  The  result  was  a  lateral 
incision  in  the  cervix,  superficial  at  its  upper  extremity  but  becoming 
deeper  as  it  passed  downwards  till  at  its  base  it  completely  divided  the 
intra-vaginal  portion.  The  instrument  was  re-introduced  and  a  similar 
incision  made  on  the  opposite  side.  The  extent  of  this  bilateral  incision 


Fig.  152. 

Sir  James  Simpson's  metrotome  (S'r  J.  Y.  Simpson),     a,  shows  position  of  blade  when  protruded. 

is  seen  in  Fig.  153.     The  result  of  this  operation  is  that  the  narrow  circu- 
lar os  becomes  an  orifice  with  gaping  lips. 

By  effecting  this  change  in  the  form  of  the  os  uteri,  we  not  only  re- 
move the  obstruction  to  the  outflow  of  the  menstrual  blood  but  also 
favour  the  entrance  of  the  spermatozoa  into  the  cervical  canal.  As  Sir  J. 
Y.  Simpson  points  out,  we  make  the  nulliparous  os  resemble  in  form  the 
os  of  a  uterus  which  has  been  pregnant ;  that  is,  instead  of  beiug  circular 
and  small,  it  is  made  transverse  and  gaping  (cf.  Figs.  154  and  155).  That 


258  MANUAL    OF    GYNECOLOGY. 

a  patulous  condition  of  the  os  and  cervical  canal  greatly  favours  fertilisa- 
tion is  proved  by  the  readiness  with  which  conception  follows  abortion. 

Other  forms  of  metrotome  have  been  introduced  by  Coghill,  Green- 
.halgh,  Savage,  and  Routk  Those  of  Greenhalgh  and  Savage  are  double- 
bladed,  while  that  of  Routh  has  the  blades  curved. 

We  are  indebted  to  Marion  Sims  for  substituting  the  scissors  for  the 


Fig.  153. 

Incision  made  by  metrotome  (Sir  J.  Y.  Simpson).  The  dark-shaded  portion,  B,  represents  extent  of  incision  ; 

A,  os  internum. 

metrotome.  The  objections  to  the  latter  instrument  are  that  we  do  not 
know  how  deep  the  incision  is  being  made,  nor  whether  both  incisions 
are  being  made  equally.  The  practitioner  will  find  the  scissors  easier  to 
handle  than  the  knife.  A  pair  of  ordinary  strong  scissors  will  do,  pro- 
vided they  are  sharp  and  the  cervix  be  firmly  held  with  the  volsella.  The 


Fig.  154. 

Nulliparons  os  uteri  (Sir  J.  Y.  Simpson). 

scissors  of  Kuchenmeister  (Fig.  110)  and  Hart  (Fig.  Ill)  have  this  advan- 
tage, that  the  hook  on  the  external  blade  prevents  the  cervix  from  slipping 
out  as  the  section  is  being  made. 

The  operation  is  performed  as  follows :  The  patient  is  placed  semi- 
prone.     The  Sims  speculum  is  passed  and  held  by  an  assistant ;  if  Bat- 


AFFECTIONS  OF  THE  UTERUS.  259 

tey's  speculum  is  used,  an  assistant  is  not  necessary.  "We  recommend 
that  this  operation,  as  indeed  all  operations  on  the  cervix  or  vagina,  be 
performed  under  continual  irrigation  from  a  vaginal  douche.  It  is  diffi- 
cult to  do  this  in  private  practice  and  without  assistants ;  but,  if  always 
carried  out,  the  possibility  of  cellulitis  and  peritonitis  is  reduced  to  n, 
minimum.  If  the  irrigation  be  not  employed,  the  vagina  should  be  thor- 


Fig.  155. 
Parons  os  uteri  (Sir  J.  Y.  Simpson). 

oughly  syringed  beforehand  with  1  to  40  carbolic  acid  solution.  The  an- 
terior lip  of  the  cervix  is  laid  hold  of  with  the  volsella ;  the  scissors  are 
introduced,  the  straight  blade  being  passed  within  the  cervical  canal ;  the 
point  or  hook  of  the  external  blade  is  carried  to  about  half-way  up  the  cer- 
vix (see  Fig.  156  and  Fig.  148)  and  the  section  made.  In  many  cases,  all 
that  is  necessary  is  to  divide  the  ring  round  the  os  externum  ;  when  this 


Tig.  158. 
Showing  the  bilateral  division  of  the  cervix,  with  Knchenmelster's  scissors  (Barnes). 

is  divided,  we  find  the  cervical  canal  dilated  above  it.  In  this  respect  this 
operation  differs  from  that  of  dividing  the  posterior  lip  (see  under  Ante- 
flexion),  in  which  it  is  essential  to  make  the  scissors  cut  as  far  as  the  re- 
flexion of  the  mucous  membrane  at  the  fornix.  Should  the  cervical  canal 
not  be  patulous,  it  may  be  necessary  to  make  the  incisions  extend  deeper 
—to  the  base  of  the  vaginal  portion.  There  is  generally  not  much  bleed- 
ing after  the  section  is  completed,  but  we  watch  a  few  minutes  to  see.  If 


260  MANUAL    OF    GYNECOLOGY. 

there  is  none,  a  vaginal  tampon  is  not  required.  Should  hemorrhage  oc- 
cur, some  perchloride  of  iron  is  swabbed  on  the  cut  surface  and  a  vaginal 
tampon  of  lint  soaked  in  carbolised  oil  is  applied. 

More  important  than  the  incision  is  the  after-treatment.     The  patient 
must  be  seen  on  the  following  day,  and  every  second  day  for  a  fortnight, 


Fig.  157. 

Glass  plug  to  keep  the  cervix  patulous  after  division  (Thomas). 

and  the  finger  passed  in  on  each  occasion  to  prevent  union  of  the  cut  sur- 
faces and  dilate  the  cervical  canal.  To  keep  the  canal  open,  Thomas 
recommends  the  use  of  a  glass  cervical  plug  (Fig.  157),  kept  in  position 
by  a  solid  plate  of  the  form  of  an  Albert  Smith  pessary.  This  is  useful 
after  division  of  the  posterior  lip,  but  we  think  that  it  is  not  necessary- 
after  the  bilateral  incision. 


CHAPTER  XXV. 
ATEOPHY  OF  THE  CERVIX  AND  UTERUS;  SUPERINYOLUTION. 

WE  meet  with  an  atrophic  condition  of  the  cervix  and  uterus  under  four 
different  conditions  : — 

1.  As  a  congenital  condition  ; 

2.  Associated   with   certain  constitutional  affections,  as  phthisis, 

scrofula,  chlorosis ; 

3.  In  the  puerperal  uterus,  as  the  result  of  superinvolution  ; 

4.  After  the  menopause. 

Should  the  student  find  on  vaginal  examination  that  the  cervix  is  small 
and  projecting  only  slightly  into  the  vagina,  and  on  bimanual  examination 
that  the  body  of  the  uterus  is  found  with  difficulty  and  is  smaller  than  it 
should  be,  he  must  next  ascertain  which  of  the  above-mentioned  causes 
has  produced  the  atrophy. 

The  history  will  enable  him  to  form  his  diagnosis.  With  the  congenital 
condition  there  is  a  history  of  amenorrhoea  or  scanty  menstruation  since 
puberty,  of  sterility  if  the  patient  has  entered  married  life,  and  of  hysteria 
and  other  disturbances  of  the  nervous  system  which  usually  accompany 
imperfect  development  of  the  uterus.  The  constitutional  condition,  and  es- 
pecially the  state  of  the  blood  and  of  the  lungs,  in  other  cases  enables  him 
to  account  for  the  condition  of  the  uterus.  Probably  the  small  uterus 
found  in  chlorotic  patients  is  a  congenital  condition,  and  not  secondary  to 
the  constitutional  state.  If  the  atrophic  condition  be  the  result  of  super- 
involution,  there  is  a  history  of  childbirth  with  non-appearance  of  men- 
struation after  it.  With  regard  to  the  menopause,  the  age  of  the  patient 
is  the  chief  guide  ;  we  must  remember  the  possibility  of  an  early  meno- 
pause, as  early  as  at  the  age  of  thirty-five. 

The  only  atrophic  condition  which  we  shall  consider  here  is  that  oc- 
curring in  the  puerperal  uterus  as  the  result  of  superinvolution.  To  Sir 
James  Simpson's  description  of  this  condition  we  are  chiefly  indebted. 


262  MANUAL    OF    GYNECOLOGY. 

SUPERINVOLUTION  OF  THE  UTERUS. 

LITERATURE.  Frommel — Ueber  puerperale  Atrophie  des  Uterus :  Zeits.  f.  Geburts. 
und  Gynak.,  Bd.  vii.,  H.  ii.,  S.  305.  Jaquet — Berl.  Beitrage  zur  Geburts.  und 
Gynak.,Bd.  ii.,  S.  3.  Klob—  Patholog.  Anatom.  der  weib.  Sexualorgane  :  Wien., 
1864,  S.  205.  Simpson,  Sir  J.  T.—  Med.  Times  and  Gazette,  1861.  Diseases  of 
Women  :  Edin.,  1873,  p.  547. 

PATHOLOGY. 

The  uterus  is  smalL  Its  external  length  may  be  reduced  from  the 
normal  3  to  If  inches.  The  walls  are  thin  and  flaccid,  sometimes  of  a 
dense  and  fibrous  consistence.  The  vaginal  portion  projects  only  slightly 
in  to.  the  vagina,  and  may  be  almost  flush  with  the  vaginal  roof.  The  os  may 
be  relatively  patulous,  or  contracted,  so  as  only  to  admit  a  probe.  The 
uterine  cavity  is  reduced  to  2£,  2,  or  even  1|  inches  in  length.  The  ova- 
ries are  atrophied,  and  sometimes  show  an  increase  of  fibrous  tissue  in 
their  structure.  The  accompanying  specimen  (Fig.  158),  described  by  Sir 
James  Simpson,  illustrates  these  points. 

ETIOLOGY. 

As  to  the  frequency  of  this  condition,  Frommel  found  it  present  in  28 
out  of  3,000  gynecological  cases,  that  is  in  almost  1  per  cent.  The  reason 
why,  in  certain  cases,  the  process  of  involution  during  the  puerperium  goes 
on  till  the  uterine  cavity  is  reduced  to  less  than  2£  inches  in  length  is  not 
known.  Protracted  Lactation  seems  the  most  important  cause  (Frommel). 
We  have  seen  this  in  two  cases,  and  Chiari  has  also  drawn  attention  to  it. 
In  some  instances  there  is  a  history  of  great  loss  of  blood  at  the  confine- 
ment ;  in  a  case  of  this,  reported  by  Whitehead, '  the  atrophic  changes  had 
progressed  so  far  that  no  trace  of  a  uterus  was  found  on  the  most  careful 
examination.  In  other  instances  pelvic  peritonitis  has  occurred  during  the 
puerperium  ;  this  can  produce,  we  know,  atrophy  of  the  ovary  through 
binding  it  down  with  adhesions  ;  and  atrophy  of  the  ovaries  may  lead  to 
atrophy  of  the  uterus.  It  is  also  associated  with  the  tubercular  diathesis 
(Klob). 

1  British  Med.  Journ.,  Oct.,  1872. 


AFFECTIONS    OF    THE    UTEIiUd. 


~     -3 


201  MANUAL    OF    GYNECOLOGY. 


SYMPTOMS. 

Continued  amenorrhcea  is  the  symptom  which  leads  the  patient  to 
seek  advice.  After  she  has  ceased  nursing,  she  expects  the  flow  to  return. 
It  does  not  do  so,  however,  even  after  months  have  passed.  Pain  in  the 
back,  weakness  and  hysterical  symptoms  are  also  present. 

DIAGNOSIS. 

The  small  cervix  at  once  suggests  what  the  condition  is.  We  some- 
times have  difficulty  in  making  out  the  uterus  bimanually  ;  here  the  ex- 
amination per  rectum,  combined  with  the  volsella,  is  useful.  The  best 
idea  of  the  size  of  the  uterus  is  gained  by  pressing  the  ball  of  the  finger 
in  the  rectum  against  the  isthmus  of  the  uterus,  and  then  moving  the 
uterus  upwards  and  down  wards  upon  the  finger  which  can  thus  estimate 
accurately  its  size  ;  having  done  this,  we  make  more  traction  on  the  uterus 
to  bring  it  as  far  down  as  possible,  and  examine  the  ovaries. 

The  sound  must  be  used  with  care,  as  it  easily  perforates  the  thin  walls 
of  the  uterus.     It  does  not  pass  into  the  uterus  as  far  as  the  2£  in.  knob. 
Differential  diagnosis  must  be  made  from — 

Congenital  malformation ; 
Congenital  atrophy  ; 
Senile  atrophy. 

TREATMENT. 

This  consists  in  stimulating  the  uterus  to  hypertrophy  by  placing  a 
foreign  body  in  its  cavity.  The  galvanic  intra-uterine  stem  pessary  of  Sir 
James  Simpson  is  the  best  instrument  for  this  purpose.  The  stem  is 
made  in  its  upper  half  of  zinc,  in  its  lower  half  of  copper  ;  the  bulb  is  also 
of  copper.  The  form  of  it  is  seen  in  Fig.  159,  which  is  drawn  full-size.  The 
stem  should  always  be  shorter  than  the  uterine  cavity  by  a  quarter  of  an 
inch  ;  otherwise  it  may  perforate  the  fundus.  It  is  introduced  as  follows. 
The  cervix  is  laid  hold  of  with  the  volsella  to  draw  it  towards  the  vaginal 
orifice  and  to  steady  it.  The  stem  is  held  with  the  bulb  between  the  fin- 
ger and  thumb,  and  passed  into  the  cervix  for  about  an  inch.  If  the 
vaginal  orifice  be  too  narrow  to  allow  of  this  manipulation,  the  bulb  is 
fixed  on  the  end  of  a  staff  (Fig.  159)  and  thus  carried  in.  Once  the  stem 
is  within  the  cervix  difficulty  is  sometimes  felt  in  pressing  it  onwards. 


AFFECTIONS    OF   THE    UTERUS. 


265 


The  following  manoeuvre  facilitates  this.  Pass  the  index  finger  of  the 
right  hand  well  upwards  into  the  rectum  tiU  the  point  of  it  gets  fairly 
behind  the  cervix  and  fixes  it ;  now  put  the  thumb  into  the  vagina,  and 
with  it  make  pressure  on  the  bulb  which  is  thus  between  the  thumb  and 


Fig.  159. 

Galvanic  intra-uterine  stem  (i/i).    a,  perforation  in  bulb  of  stem  for  the  stuff,  c,  used  to  introduce  it ;  the 
stem  is  of  copper  from  6  to  d,  of  zinc  from  d  to  the  point  (Sir  J.  Y.  Simpson). 

finger  (the  posterior  wall  of  the  vagina  of  course  intervening),  and  the 
stem  can  be  satisfactorily  pushed  home. 

A  glycerine  plug  is  passed  to  keep  the  stem  in  position  at  first.  The 
patient  should  keep  at  rest  for  one  day  after  the  stem  has  been  introduced, 
and  should  be  instructed  to  send  at  once  if  pain  is  felt  in  the  pelvis  ;  we 
have  seen  pelvic  inflammation  follow  the  introduction  of  a  stem  pessary. 
Should  the  practitioner  not  be  within  call,  it  is  a  good  plan  to  tie  one 
piece  of  string  to  the  bulb  and  another  to  the  plug,  so  that  the  patient  can 
draw  them  out  herself  when  symptoms  of  inflammation  arise.  The  pes- 
sary can  be  worn  for  months  without  being  removed,  does  not  interfere 
with  menstruation,  and  keeps  its  position  without  any  plug  in  the  vagina. 


CHAPTEE  XXYI. 
HYPERTROPHY  OF  THE  CERVIX;    AMPUTATION. 

LITERATUKE. 

Byrne — Amputation  and  Excision  of  the  Cervix  Uteri:  Trans.  Americ.  Gyn.  Soc., 
Boston,  II.,  pp.  57  and  110.  Oalabin — Lond.  Obst.  Journ.,  Sept.,  1878.  Goodell 
— Clinical  Notes  on  the  Elongations  of  the  Cervix  Uteri  :  Am.  Gyn.  Trans.,  1880, 
p.  268.  Hegar  und  Kaltenbach— Operative  Gynakologie  :  Stuttgart,  1881,  S.  445. 
Huguier — Memoires  snr  les  Allongements  Hypertrophiques  du  Col  de  1'Uterus, 
Paris,  1860.  Leblond — Op.  cit.,  p.  448.  MarckwaM — Ueber  die  kegelmantel- 
form.  Excision  der  Vaginal-Portion,  etc. :  Archiv.  f.  Gyn.,  Bd.  viii.,  S.  48. 
Schroeder— Charita-Annalen,  1878;  and  Zeitschrift  f iir  Geburt.  u.  Gyn.,  Bd.  iii., 
S.  419  ;  Bd.  vi.  Hft.  2,  S.  218.  Simon—  Monatsch.  f.  Geburtskunde,  xiii  ,  S.  418. 
Sims,  Marion — Uterine  Surgery,  p.  264. 

HYPERTROPHY  of  the  whole  uterus  occurs  in  two  forms  : — 

1.  Hypertrophy  of  the  muscular  tissue — in  pregnancy  ; 

2.  Hypertrophy  of  the  connective  tissue — in  subinvolution   and 

chronic  metritis,  both  of  which  will  be  considered  under 
chronic  metritis. 
Hypertrophy  of  the  cervix  alone  calls  for  special  notice  here. 

HYPERTROPHY  OF  THE  CERVIX. 

Under  this  head  we  consider  two  conditions  : — 

A.  Hypertrophy  limited  to  the  vaginal  portion,   which  is  a  dis- 

tinct primary  lesion ; 

B.  Hypertrophy  of  the  supra-vaginal  portion  which  is  usually  asso- 

ciated with  hypertrophy  of  the  body  of  the  uterus,  this 
occurs  in  prolapsus  uteri  and  is  probably  secondary  to  that 
condition. 

A.    HYPERTROPHY    OF   THE   VAGINAL    PORTION. 

Pathology. — The  peculiarity  of  this  condition  is  that  the  cervix  is  nor- 
mal in  every  respect  except  length  (Fig.  161).     The  mucous  membrane 


AFFECTIONS    OF   THE    UTERUS.  267 

and  the  subjacent  tissue  are  not  thickened,  so  that  the  diameter  of  the 
cervix  is  not  much  increased.  As  the  result  of  the  increase  in  length,  the 
conical  apex  of  the  cervix  comes  to  lie  immediately  behind  the  hymen  and 


Fig.  160. 

Hypertrophied  vaginal  portion,  c,  protruding  through  the  vulva.    The  sound  hni  passed  very  far  Into  the 

small  os,  o  (Schroeder). 

may  protrude  through  the  vaginal  orifice  (Fig.  160).  The  os  externum 
is  often  small. 

Etiology. — This  condition  is  a  true  hypertrophic  growth  ;  it  is  not  very 
common  and  the  cause  of  it  is  unknown.  As  it  occurs  in  the  virgin,  it  is 
probably  congenital.  Sometimes  it  does  not  attract  attention  till  the 
patient  enters  married  life,  when  it  produces,  as  a  rule,  sterility,  because 
the  form  of  the  cervix  interferes  with  conception. 

The  cervix  is  frequently  thickened  as  the  result  of  chronic  inflammation 
consequent  on  laceration  of  the  cervix  in  child-birth  ;  this  is  not  a  true 
hypertrophic  growth,  and  will  be  considered  under  Laceration  of  the 
Cervix  (Chap.  XXVtt). 

Symptoms. — The  symptoms  are  due  to  the  presence  of  the  hypertro- 
phied  cervix  in  the  vagina.  There  is  bearing  down  as  in  prolapsus  uteri, 
irritation  of  the  mucous  membrane  of  the  vagina  and  consequent 
leucorrhcea,  discomfort  on  walking  about  and  on  rising  suddenly.  If  the 
cervix  protrude  beyond  the  vulva,  ulceration  of  its  mucous  membrane 
and  excoriation  are  produced. 

Diagnosis. — This  presents  no  difficulty.     The  fornices  are  found  in 


268  MANUAL    OF    GYNECOLOGY. 

their  normal  position  on  vaginal  examination  (see  Fig.  161),  the  fundus 
uteri  at  its  normal  height  in  the  pelvis  on  bimanual  examination.  These 
two  clinical  facts  indicate  that  the  low  position  of  the  apex  of  the  cervix 
is  not  due  to  a  descent  of  the  fundus  but  a  hypertrophy  of  the  cervix,  and 
that  the  hypertrophy  of  the  cervix  is  limited  to  the  portion  which  projects 
into  the  vagina  (cf.  Fig.  161  with  Fig.  169  and  Fig.  170).  The  sound 
will  pass  five  inches  or  more  into  the  cervical  canal :  as  the  patient  is 
usually  a  nullipara  and  the  abdominal  walls  therefore  firm,  it  facilitates 


Fig.  161. 

Hypertrophy  of  intra-vaginal  portion  of  cervix.    Neither  fornix  is  obliterated  (Schroeder).    Section  of 

pelvis  seen  in  Fig.  160. 

the  bimanual  to  do  it  with  the  sound  in  the  uterus.  The  combined  recto- 
vaginal  examination  shows  that  the  uterus,  above  the  vagina,  is  of  normal 
length. 

Treatment. — This  consists  in  amputation  of  the  cervix,  which  is  the  only 
course  open  to  us,  because  the  hypertrophy  will  not  diminish  but  rather 
increase.  Amputation  is  performed  by  three  methods  : — 

1.  Scissors  or  knife, 

2.  Ecraseur, 

3.  Galvano-caustic  wire. 

f 
The  successive  improvements  in  the  method  of  amputation  with  the  • 

knife  may  be  thus  tabulated  ;  by  Marion  Sims  was  made  the  advance  of 
covering  the  stump  with  mucous  membrane. 

(1.)   Old  method.     Circular  amputation ;  raw  surface  touched  with 
caustic  or  cautery  ;  healing  by  granulation. 


AFFECTIONS    OF   THE    UTERUS. 


269 


(2.)  Sims'  method.  Circular  amputation;  vaginal  mucous  mem- 
brane stitched  to  vaginal  mucous  membrane  ;  healing  partly 
by  first  intention  (Fig.  162). 


Fig.  162. 
Sims'  method  of  passing  the  suture.    Vaginal  mucous  membrane  stitched  to  vaginal  (Sims). 

(3.)  Hegar's  method.  Circular  amputation ;  vaginal  mucous  mem- 
brane stitched  to  cervical  mucous  membrane  (Fig.  167) ; 
healing  by  first  intention. 

(4.)  Simon  and  Marckwald.  Flap  amputation  by  wedge-shaped 
excision  of  lips  separately  (Fig.  163) ;  vaginal  mucous  mem- 
brane stitched  to  cervical  on  each  lip  (Fig.  165) ;  healing  by 
first  intention. 

As  there  is  often  considerable  hemorrhage,  it  is  well  to  place  a  con- 
stricting band  on  the  cervix  above  the  point  of  section.     A  common 


Fig.  163. 

Marckwald's  method  of  splitting  the  cervix  into  an  anterior  and  posterior  lip,  and  then  uniting  cervical  to 
vaginal  mucous  membrane  (Schroedcr). 

India-rubber  umbrella  ring  serves  admirably  to  control  hemorrhage  in 
this  and  in  Emmet's  operation  for  lacerated  cervix.     The  ring  is  warmed 


270  MANUAL    OF    GYNECOLOGY. 

beforehand  to  make  it  less  rigid,  and  slipped  over  the  handle  of  the  vol- 
sella  which  grasps  the  cervix  ;  after  the  operation  is  completed  we  notch 
it  with  the  scissors,  and  thus  gradually  slacken  it  before  finally  cutting  it 
through. 

The  best  method  of  performing  the  amputation  is  to  split  the  cervix 
by  a  transverse  incision  into  an  anterior  and  posterior  lip  ;  then  amputate 
each  lip  separately,  making  the  line  of  amputation  wedge-shaped ;  finally 
bring  together  the  projecting  flaps  of  vaginal  and  cervical  mucous  mem- 
brane with  wire  sutures. 

The  Operation. — The  instruments  required  are  the  following : — 

Antiseptic  douche, 
Sims'  speculum, 
Spatulse, 
Volsella, 

India-rubber  ring, 
Straight  needles  fixed  on  handles, 
Silver  wire, 
Bistouries, 
Dissecting  forceps, 
Blunt  hook, 
,  Scissors, 

Artery  forceps, 

Small  curved  needles  and  needle  holder. 

A.  R.  Simpson  operates  as  follows  :  The  patient  is  placed  in  the  lithot- 
omy posture.  Continued  irrigation  with  a  2  p.  c.  solution  of  carbolic 
is  employed.  The  cervix  is  drawn  down  with  volsella ;  an  India-rubber 
ring  is  passed  over  the  volsella  on  to  the  cervix  and  placed  so  as  to  con- 
strict the  cervix  just  below  the  fornices  (Fig.  164).  The  cervix  is  pierced 
in  the  middle  line  from  below  with  a  straight  needle  on  a  fixed  handle. 
A  straight  needle  passes  more  easily  through  the  dense  tissue  of  the 
cervix ;  if  the  cervix  does  not  project  sufficiently  through  the  vulva  to 
allow  of  the  straight  one  being  used,  a  curved  one  is  required.  When 
the  point  of  the  needle  projects  as  far  as  the  eye,  this  is  threaded  with  u 
long  wire  suture  and  then  drawn  back  (Fig.  164,  If,  N).  A  similar 
thread  is  carried  through  on  either  side  of  the  middle  line  so  that  the 
cervical  canal  is  pierced  with  three  long  sutures,  one  in  the  middle  of  it, 
and  one  at  each  side  of  it.  The  cervix  is  now  split  horizontally  with  the 


AFFECTIONS    OF   THE    UTERUS. 


271 


knife  or  scissors  so  as  to  divide  it  into  an  anterior  and  posterior  lip  ;  this 
horizontal  section  is  carried  as  far  as  the  sutures,  so  that  they  are  exposed 


Fig.  164. 

Diagram  of  amputation  of  cervix.  To  the  right  is  seen  the  cervix  with  the  ring  constricting  it,  a  suture, 
If,  N,  in  position,  the  cervix  split  and  the  line  of  amputation  marked  1  to  6 ;  a,  /,  anterior,  and  p,  f,  poste- 
rior fornix.  To  the  left  is  seen  the  cervix  in  cross-section  ;  two  threads  are  passed  and  the  needle  carried 
through,  but  not  yet  threaded  with  the  wire  w. 

at  the  bottom  of  the  incision.  We  now  hook  them  up  in  turn  and  drag 
the  loop  of  each  down  through  the  wound  (Fig.  164,  m,  n).  Each  loop 
is  then  divided;  the  three  sutures  are  thus  converted  into  six — three 


71    N 

Fig.  165. 

The  suture  >fff  has  been  divided  and  the 
halves  brought  down  as  3/m,  JVrc;  the  lateral 
ones  also,  x,  x  and  y,  y  are  additional  side 
sutures. 


Fig.  166. 

Appearance  of  stnmp  of  Fig.  168  when  snlurcs  tire 
twisted  up. 


through  the  base  of  each  lip.  A  portion  of  the  anterior  lip  is  now  excise.! 
along  the  line  1,  2,  3.  The  sutures  are  now  used  to  bring  together  the 
margins  of  this  amputation.  The  posterior  lip  is  nest  treated  in  the  same 


272  MANUAL    OF    GYNECOLOGY. 

way.  Additional  sutures  are  put  in  on  each  side  to  close  in  the  side  walls 
of  the  cervix  (Fig.  165,  x  and  y}.  When  the  cervix  is  not  unusually 
thick,  these  lateral  sutures  are  passed  as  in  Fig.  165  ;  but  when  the  cervi- 
cal waUs  are  thick,  it  makes  a  neater  stump  to  bring  these  sutures  also 
out  through  the  cervical  canal  and  unite  vaginal  to  cervical  mucous  mem- 
brane all  round  (see  Fig.  167,  x  and  y). 

The  peculiarity  of  this  method  of  operating  is,  that  the  sutures  are 
introduced  before  the  knife  is  used.  The  advantages  of  this  are  the  fol- 
lowing :  it  is  easier  to  pass  the  needle  through  the  dense  tissue  when 
the  cervix  is  fixed  with  the  volsella  ;  the  sutures  serve  as  a  means  of  trac- 
tion when  the  portion  grasped  by  the  volsella  has  been  cut  away  ;  we  can 
ligature  the  flaps  immediately  after  the  lip  has  been  amputated  and  thus 


Pig.  167. 
Mode  of  passing  sutures  when  stump  is  very  thick. 

check  hemorrhage — this  refers  specially  to  amputation  in  prolapsus  uteri, 
where  we  cannot  constrict  the  cervix  with  a  ring. 

The  appearance  of  the  stump  after  the  sutures  have  been  twisted  is 
seen  at  Fig.  166.  Wire  sutures  are  most  convenient  in  all  operations  on 
the  cervix  or  vagina,  because  they  are  most  easily  removed.  They  should 
be  twisted  or  tied  ;  the  ends  are  left  long  enough  to  protrude  clear  of  the 
vulva ;  the  free  ends  of  the  same  suture  are  twisted  together  to  keep 
them  separate  from  the  others ;  finally,  all  the  ends  are  wrapped  in  a 
piece  of  lint  to  prevent  their  fretting  the  labia. 

Removal  of  the  Sutures. — The  sutures  are  removed  in  a  week's  time. 
The  patient  is  put  in  the  Sims  position  and  the  Sims  speculum  passed. 
Slight  traction  is  made  on  a  suture,  and  if  the  twisted  knot  is  visible,  we 
clip  the  wire  with  the  wire  scissors.  Generally  we  find  the  knot  is  em- 
bedded in  tissue  ;  in  which  case  the  rake  (Fig.  168)  is  used  to  hook  up 
the  loop.  In  snipping  the  loop  we  place  one  blade  of  the  scissors  under 
it,  and  then  press  the  tissue  back  from  the  wire  so  as  to  divide  the  loop 
as  far  away  from  the  knot  as  possible. 


AFFECTIONS    OF    THE    T'TEPJ*?. 


Amputation  with  tho  foraseur  or  with  the  (]<ih-min-cau*fi<*  ii-i'r*'  is  not 
such  a  neat  method  of  operating  as  with  the  knife.  Further,  there  is  lia- 
bility to  closure  of  the  cervical  canal  through  cicatrisation:  this  maybe 
prevented  by  introducing  a  stem  pessary  after  .'imputation.  The  galvano- 
caustic  wire  is  recommended  by  Barnes,  Thomas,  and  others  ;  its  use  has 


Fi;,'.   UN. 
Point  of  rake  :  although  finely  made,  it  FhouM  he  bhint. 

been  followed  witli  remarkably  good  results  in  the  hands  of  Bvrne  of 
Brooklyn,  whose  valuable  paper  on  this  subject  should  be  consulted. 

The  method  of  using  the  ecrascur  and  galvano-cauterv  will  be  de- 
scribed under  Amputation  of  the  Cervix;  for  Carcinoma  (see  Chap.  XL.). 

With  the  galvano-caustic  wire  we  must  see  that  the  wire  does  not  .*///> 
doiniifarrff!,  and  thus  '"scalp"  instead  of  amputating  the  cervix.  The  fart 
that  the  galvano-cautery  diminishes  hemorrhage  is  of  no  advantage  in 
amputating  the  hypertrophied  cervix.  The  use  of  the  india-rubber  ring 
makes  this  a  bloodless  operation  ;  and  tho  introduction  of  the  nituivs  in 
the  way  described  minimizes  the  danger  of  hemorrhage  when;  the  ring 
is  not  employed. 

II.    HvrKRTiionrY  or  Tin;  sri-i:  \-v.\r.iN.u.  IMIKTION. 

The  existence  of  hypertrophy  limited  to  the  supra-vaginal  portion  of 
the  cervix  and  not  affecting  tho  body  of  the  uterus  cannot  be  d,  ti  nnii  >  i 


means  of  ascertaining  in  a  case  of  hypertrophy  \vh<  re  the  p 
limit  of  the  cervix  lies.  The  position  of  (lie  os  internum  is  not  indic.ati  1 
l>y  tiio  sound,  and  the  distance;  to  which  the  utero-vesical  [touch  of  pi  n 
toneum  descends  can  only  be  ascertained  on  post-mortem  i  \annnat  i"H. 
We  cannot  aflirni,  tlier(:fore.  that  the  hypertrophy  is  limited  to  the  supra- 
vaginal  portion  of  the  cervix  and  that  it  does  not  affect  the  body  of  the 
uterus  as  well. 

In  the  present  state  of  our  knowledge  it  is  impossible  to  say  \\hetln-r 
this  hypertrophy  is  primarv  or  secondary.  \\V  1>,  li<  ve  that  in  tin-  great 
proportion  of  cases  it  is  secondary  to  prolapsus  uti  ri. 

By  French  and  by  manv  (iermaii  gynecologists,  however,  hypertrophy 
VOL.  I.  —  18 


274  MANUAL    Otf    GYNECOLOGY. 

of  the  supra-vaginal  portion  of  the  cervix  is  considered  a  distinct  primary 
lesion.  Huguier  first  drew  attention  to  the  increase  in  the  length  of  the 
uterine  canal  in  cases  described  as  prolapsus  uteri ;  he  affirmed  that  the 


Fig.  169. 
Hypertrophy  of  intermediate  portion  of  cervix.    The  anterior  fornix  is  obliterated  (Schroeder). 

fundus  uteri  always  remained  in  its  normal  position,  and  that  the  os  ex- 
ternum  came  to  lie  outside  the  vulva  because  the  cervix  had  increased  in 
length  ;  this  hypertrophied  condition  of  the  cervix  was  occasioned  by  a 


Fig.  170. 
Hypertrophy  of  supra-vaginal  portion  of  cervix.    Both  fornices  are  obliterated  (Schroeder). 

prolapse  of  the  vaginal  walls  which  made  traction   on  the  cervix,  and 
thereby  stimulated  it  to  increased  growth. 

By  these  gynecologists,  three  forms  of  cervical  hypertrophy  are  de- 
scribed according  to  the  portion  of  the  cervix  which  is  hypertrophied. 
The  division  of  the  cervix  into  three  portions — a  vaginal,  an  intermediate, 


AFFECTION'S  OF  THE  UTERUS.  275 

and  a  supra-vaginal  portion— has  been  already  described  (see  page  16). 
The  vaginal  portion  is  limited  superiorly  by  the  insertion  of  the  anterior 
fornix ;  the  intermediate  by  that  of  the  posterior  fornix  ;  the  supra-vaginal 
by  the  os  internum.  Hypertrophy  of  the  vaginal  portion  is  characterised 
by  the  persistence  of  both  fornices  in  their  normal  position  ;  it  has  been 
already  described  (see  Fig.  161).  In  hypertrophy  of  the  intermediate 
portion  the  posterior  fornix  remains,  while  the  anterior  is  obliterated  (see 


Fig.'l7L 
Prolapsus  nterl  with  cervical  hypertrophy  (Barnes) ;  p,  p,  peritoneum. 

Fig.  169).  In  hypertrophy  of  the  supra-vaginal  portion  both  anterior  and 
posterior  fornices  are  obliterated  (see  Fig.  170). 

In  the  accompanying  preparation  (Fig.  171),  described  by  Barnes,  the 
hypertrophy  affects  both  uterus  and  cervix — if  we  take  the  utero-vesical 
pouch  of  peritoneum  as  indicating  the  position  of  the  os  internum. 
Winckel  figures  and  describes  a  similar  specimen  (Die  Pathologie  der 
weiblichen  Sexual- Organ e,  Tafel  XlXa.). 

As  we  have  already  said,  we  consider  supra-vaginal  hypertrophy  to  be 
merely  one  of  the  consequences  of  prolapsus  uteri,  under  which  its  etiol- 
ogy, pathology,  and  diagnosis  will  be  considered  (v.  Section  VIL). 


276 


MANUAL    OP    GYNECOLOGY. 


Treatment. — The  amputation  of  the  hypertrophied  cervix,  though  a 
part  of  the  treatment  of  prolapsus  uteri,  is  most  conveniently  considered 
here,  as  it  resembles  the  amputation  in  simple  primary  hypertrophy  of 
the  vaginal  portion.  In  amputating  for  supra-vaginal  hypertrophy,  how- 
ever, the  relations  of  the  bladder  and  peritoneum  of  the  pouch  of  Douglas 
require  to  be  considered.  The  bladder  invariably  descends  for  a  varying 
distance  in  relation  to  the  front  of  the  hypertrophied  cervix.  The  peri- 
toneum of  the  pouch  of  Douglas,  inasmuch  as  it  lines  the  upper  part  of 


Amputation  of  hypertrophied  cervix  in  prolapsus  uteri.  B,  sound  in  bladder  ;  p,  peritoneum  of  pouch 
of  Douglas.  The  sutures  are  passed  as  M,  N,  and  the  cervix  split  laterally,  so  as  to  form  an  anterior  lip 
Which  is  amputated  along  lines  1,  2,  3,  and  a  posterior  lip  amputated  along  4,  5,  6. 

the  posterior  vaginal  wall,  will,  when  that  wall  is  averted,  dip  down  along- 
side of  the  hypertrophied  cervix.  If  the  posterior  fornix  is  not  obliterated, 
the  peritoneum  will  not  descend  alongside  of  the  protruding  cervix. 

The  relations  of  the  bladder  and  peritoneum  are  represented  diagram- 
matically  in  Fig.  172.  The  line  of  reflection  of  the  posterior  vaginal  wall 
on  to  the  cervix  indicates  how  much  is  vaginal  portion,  and  by  entering 
the  needle  below  that  line  we  keep  clear  of  the  pouch  of  peritoneum. 
The  sound  passed  into  the  bladder  will  show  us  how  far  down  that  organ 
comes,  and  the  needle  is  brought  out  an  inch  below  that  point. 

The  steps  of  the  operation  are  the  same  as  in  the  former  case.  A  much 
smaller  portion  is  excised  here. 


CHAPTER  XXVH. 
LACERATION  OF  THE  CERVIX. 

LITERATURE. 

Baker— Boston  Med.  and  Surg  Jour. ,  April,  1877.  Breisky— Wiener  med.  Wochen- 
schrif  t,  1876,  Nos.  49-51  :  and  Prager  med.  Wochenschrift,  1876,  No.  18 ;  1877, 
No.  28.  Chase— Trans,  of  Med.  Soc.  of  State  of  New  York,  1878.  Dewernine— 
These  de  Paris,  1879.  Dudley— New  York  Med.  Jour.,  Jan  ,  1878.  Emmet—  Sur- 
gery of  the  Cervix  :  Am.  Jour,  of  Obst.,  Feb.,  1869  ;  ibid.,  Nov.,  1874.  American 
Practitioner :  Indianapolis,  Jan.,  1877.  Principles  and  Practice  of  Gynecology,  p. 
448  :  London,  1880.  Goodett— Laceration  of  the  Cervix :  Philadelphia,  1878. 
Hegnr — Operative  Gynakologie,  S.  538 :  Stuttgart,  1881.  Uowitz—  Gynakologiske 
os.  Obstetriciske  Meddelelser,  Bd.  I.,  Heft  3.  Kaltenbach— Ueber  tiefe  Scheiden 
— u.  Cervicalrisse  bei  der  Geburt :  Zeitschrift  f.  Geb.  u.  Gyn.,  Bd.  II.,  S.  274. 
Klein— Prager  med.  Wochenschrift,  1878,  No.  24.  Lee— The  Proper  Limitations 
of  Emmet' s Operation:  New  York  Med.  Jour.,  Sept.,  1881.  Munde — Am.  Jour,  of 
Obst.,  Jan.,  1879.  Nieberding— Ueber  Ectropium  und  Risse  :  Wiirzburg,  1879. 
Olshausen — Zur  Pathologie  der  Cervicalrisse  :  Centralbl.  f.  Gyn.,  1877,  Nr.  13. 
Pollen — St.  Louis  Med.  and  Surg.  Jour.,  May,  1868;  Richmond  and  Louisville 
Med.  Jour.,  1874;  British  Med.  Jour.,  May,  1881.  Rokitansky— Wiener  med. 
Presse,  1876,  Nr.  29.  Roser — Das  Ectropium  am  Muttermund :  Arch.  f.  Heilk., 
II.  Jahrg.,  2  H.,  1861.  Ruge  u.  Veit — Zur  Pathologie  der  Vaginal  Portion.  Simp- 
son, Sir  J.  T. — Edin.  Jour,  of  Med.  Science,  1851,  p.  152.  Skene— Proceedings 
of  Med.  Soc.  of  Kings,  June,  1878.  Sptegelberg — Ueber  Cervicalrisse,  ihre  Folgen 
u.  ihre  operative  Beseitigung:  Breslauer  artz.  Zeitschrift,  1879,  No.  1.  TJiomas 
—Op.  cit.,  p.  352. 

THE  recognition  of  laceration  of  the  cervix  as  a  distinct  and  important 
lesion,  with  the  operation  introduced  for  its  cure,  is  one  of  the  many 
gynecological  advances  of  the  last  twenty  years.  For  this  we  are  indebted 
to  the  genius  of  Dr.  Emmet,  of  New  York,  who  first  drew  attention  to  the 
clinical  significance  of  the  lesion  and  elaborated  the  operation  for  its  re- 
moval. Sir  James  Simpson  had  previously  drawn  attention  to  its  frequent 
occurrence,  and  its  importance  as  a  diagnostic  of  parturition.  Roser,  of 
Marburg,  had  described  the  pathology  of  the  condition  ;  but  its  importance 


278  MANUAL    OF    GYNECOLOGY. 

as  a  factor  in  uterine  disease  was  brought  into  notice  by  Emmet's  first 
paper  which  was  published  in  1869,  seven  years  after,  he  had  instituted 
the  operation  for  its  cure. 

As  the  subject  of  laceration  has  only  recently  received  attention  and  is 
at  present  a  quonstio  vexata  in  gyneocology,  we  have  given  a  full  bibli- 
ography. After  the  writings  of  Emmet  himself,  the  student  might  refer  to 
Roser,  Huge,  and  Veit  for  the  pathology  of  the  lesion  ;  to  Munde's  article 
for  diagnosis ;  and  to  the  papers  by  Fallen  and  Lee  for  operative  treat- 
ment. 

PATHOLOGY. 

The  commonest  seat  of  the  laceration  is  to  the  front  and  left  side  of 
the  cervix,  probably  because  the  long  diameter  of  the  child's  head  is  most 
commonly  in  the  right  oblique  diameter  of  the  pelvis,  and  the  thicker  end 
of  the  wedge  is  to  the  front.  The  next  in  frequency  is  a  double  lacera- 
tion— to  the  front  and  left,  and  to  the  back  and  right  sides.  Less  fre- 


Pig.  173. 

Single  laceration.     The  flaps  are  held  apart  with  a  double  tcnaculnm  (Emmet). 

quently  is  the  laceration  at  either  end  of  the  left  oblique  diameter.  We 
have  found  lacerations  to  the  front  and  right  side  in  cases  where  the  head 
presented  right  occipito-anterior.  The/brw  of  the  laceration  is  various — 
single  (see  Fig.  173),  double  (see  Plate  VIIL,  Fig.  2),  or  multiple  (see  Fig. 
174).  The  extent  of  the  laceration  varies,  from  a  mere  indentation  of  the 
ring  of  the  os  externum  to  a  gaping  fissure  separating  the  lips  of  the  cer- 
vix up  to  the  vaginal  fornices.  Occasionally  it  extends  into  the  roof  of 
the  vagina,  and  is  marked  by  a  cicatricial  band  drawing  the  cervix  to  one 


AFFECTIONS    OF   THE    UTERUS. 


279 


side.     We  have  noted  this  in  forceps  cases,  specially  when  the  forceps  had 
been  applied  before  the  os  was  dilated. 

The  result  of  the  laceration  is  that  the  mucous  membrane  of  the  cervi- 
cal canal  is  exposed  ;  and,  partly  as  an  immediate  result  of  tke  injury, 
partly  from  friction  against  the  vaginal  walls,  the  mucous  membrane  be- 
comes inflamed  (u.  Cervical  Catarrh).  The  submucous  tissue  is  also 
thickened  and  the  whole  cervix  thus  hypertrophied.  With  these  inflam- 
matory changes  there  is  eversion  of  the  lips  of  the  cervix.  Emmet  for- 
merly explained  its  occurrence  on  purely  mechanical  principles— that  the 
weight  of  the  uterus  pressed  the  cervix  against  the  posterior  vaginal  wall, 


Fig.  174 

Multiple  or  stellate  laceration  (Emmet). 

which  flattened  or  "rolled  out"  the. lips.  In  his  most  recent  utterances, 
however,  he  has  abandoned  this  theory. 

This  eversion  is  sometimes  counteracted  by  the  formation  of  cicatricial 
tissue  in  the  cleft,  which  leads  to  approximation  of  its  edges  and  even  to 
its  complete  obliteration. 

Other  pathological  conditions  are  often  associated  with  lacerations.  Ac- 
cording to  Emmet  they  are  the  result  of  it,  though  the  causal  connection 
is  not  obvious.  Cellulitis  is  the  most  important  of  these  ;  frequently  we 
find,  on  the  same  side  as  the  laceration,  a  localised  cellulitis  in  the  shape 
of  a  distinct  deposit,  or  a  tense  condition  of  the  utero-sacral  or  broad 
ligament,  accompanied  with  pain  on  pressure  through  the  fornix.  Subin- 
volution  of  the  uterus  is  also  frequently  present ;  there  is  a  formation  of 
cicatricial  tissue,  which  compresses  the  blood-vessels  and  leads  to  passive 
congestion  and  hypertrophy. 

Further,  we  find  cylindrical  epithelium  covering  the  mucous  membrane 


280  MANUAL    OF    GYNECOLOGY. 

beyond  the  limits  of  the  os  externum.  The  cylindrical  apparently  prolif- 
erates more  rapidly  than  the  squamous  epithelium,  and,  replacing  it,  pro- 
duces the  appearance  of  an  erosion  (v.  Cervical  Catarrh,  Chap.  XXVlLL. ) . 


ETIOLOGY. 

A  laceration  of  the  cervix  will  be  found,  according  to  Emmet's 
statistics,  in  32.8  per  cent,  of  parous  women  ;  according  to  Munde,  in  30 
per  cent.  Though  it  is  obvious  that  lacerations  may  be  produced  and  heal 
again  so  that  all  trace  of  them  escape  notice,  we  cannot  affirm  that  the 
cervix  is  lacerated  with  every  first  full-time  labour.  When  present, 
a  laceration  of  the  cervix  (if  we  exclude  the  possibility  of  the  cervix  having 
been  divided  artificially)  is  the  most  reliable  diagnostic  of  a  former  partu- 
rition. 

Of  the  condition  of  the  cervical  tissues  which  predispose  to  laceration 
we  at  present  know  nothing.  It  is  evident  that  an  indurated  cervix  would, 
cceteris  paribus,  be  made  more  liable  to  be  torn  than  a  flaccid  one. 

We  should  have  expected  that  lacerations  would  be  more  readily  pro- 
duced in  a  rapid  labour,  in  which  the  os  had  not  time  to  dilate.  Emmet 
and  Fallen,  however,  have  found  that  they  are  more  commonly  the  result 
of  tedious  labours. 

Barker  and  Mund6  both  draw  attention  to  the  fact  that  they  are  less 
common  among  the  wealthy  than  among  the  poor.  This  is  probably  ex- 
plained by  the  better  care  and  longer  rest  in  the  puerperium  which  the 
former  enjoy. 

During  pregnancy,  according  to  Nieberding,  slight  fissuring  of  the 
cervix  with  ectropium  is  produced.  He  examined  the  cases  admitted  to 
the  lying-in  hospital  at  Wurzburg  at  three  periods — during  pregnancy, 
as  shortly  as  possible  after  delivery,  and  on  dismissal.  Only  in  26  per 
cent,  of  the  primiparse  examined  (thirty-eight  cases)  was  the  appearance 
of  the  cervix  normal  during  pregnancy  ;  in  all  the  others  more  or  less 
ectropium  was  present.  In  50  per  cent,  there  were  in  addition  small 
fissures,  which  made  the  os  stellate  or  irregular  in  form. 

SYMPTOMS. 

It  is  very  important  to  know  what  symptoms  are  referable  to  a 
lacerated  cervix.  Those  who  revel  in  operative  treatment  ascribe  every 


AFFECTIONS  OF  THE  UTERUS.  281 

pathological  condition  in  the  uterus  to  lacerations,  while  others  altogether 
deny  that  they  have  any  pathological  significance. 

We  advance  the  following  considerations  in  regard  to  the  symptoms : 

1.  Lacerations   of  the  cervix  in  themselves  produce  no   symptoms. 
Hemorrhage  may  arise  at  the  time  of  production,  but  is  not  a  symptom  of 
the  persistence  of  the  laceration. 

2.  Other  pathological  conditions  arise  secondarily  as  the  result  of  the 
laceration,  of  which  the  most  important  is  cervical  catarrh ;  cicatricial 
tissue  in  the  cleft  may  produce  reflex  nervous  symptoms. 

3.  Pathological  conditions  are  frequently  present  along  with  the  lacer- 
ation, as  cellulitis  and  subinvolution.     These  have  each  their  own  train  of 
symptoms.     We  are  not  as  yet  in  a  position  to  say  how  these  are  related 
to  lacerations. 

We  sometimes  find  a  well-marked  laceration  by  chance,  as  it  were,  the 
patient  having  had  no  symptoms  referable  to  a  pelvic  cause. 

Frequently  she  complains  of  leucorrhcea  and  symptoms  common  to 
pelvic  or  uterine  inflammation.  Menstruation  is  often  irregular,  increased 
in  50  per  cent.  According  to  Emmet's  statistics,  this  is  in  many  cases 
due  to  subinvolution.  Neuralgia  is  sometimes  present,  which  may  show 
itself  locally  in  excessive  tenderness  to  touch  at  the  seat  of  laceration  and 
has  been  compared  to  the  sensitiveness  present  in  toothache.  In  other 
cases  it  has  taken  the  form  of  neuralgic  pain  in  the  pelvis  generally,  or 
sympathetic  neuralgia  elsewhere.  It  may  seem  a  very  gratuitous  assump- 
tion to  ascribe  neuralgia  to  this  cause  ;  we  know,  however,  that  neuralgia 
is  the  result  of  nerve-filaments  being  caught  in  the  cicatrix  of  a  stump  ; 
Emmet  and  others  record  cases  in  which  persistent  neuralgia  disappeared 
on  excision  of  the  cicatricial  plug  in  a  lacerated  cervix. 

Cataleptic  convulsions  were  present  in  an  interesting  case  recorded  by 
Sutton  (Am.  Gyn.  Trans.,  1880).  The  convulsions  could  be  produced  at 
will  by  pressing  the  finger  into  the  angle  of  laceration,  though  they  did 
not  occur  on  any  other  manipulation  of  the  cervix.  They  occurred  sponta- 
neously several  times  during  the  day.  The  excision  of  the  cicatricial 
tissue  by  Emmet's  operation  effected  a  complete  cure. 

DIAGNOSIS. 

This  presents,  in  many  cases,  no  difficulty. 

The  finger  feels  the  indentation  or  fissuring  of  the  vaginal  portion. 
Sometimes  the  cervical  canal  is  patulous,  and  admits  the  distal  phalanx  of 


282  MANUAL    OF    GYNECOLOGY. 

the  finger  easily.  Difficulty  in  diagnosis  arises  when  there  is  much 
e  version  of  the  mucous  membrane  of  the  cervical  canal  with  thickening  of 
the  cervical  tissue  ;  the  fissure  is  thus  obliterated,  because  the  circle  of 
the  os  is  not  formed  of  the  os  externum  but  of  a  higher  unfissured  portion 
of  the  canal.  This  thickening  and  the  velvety  feeling  of  the  everted 
mucous  membrane  lead  us  to  suspect  the  condition. 

The  speculum  clears  up  all  uncertainty.  "We  see  a  bright  irregular 
patch  on  one  side  of  or  surrounding  the  os  ;  from  its  granular  appearance, 
its  vascularity,  and  the  fact  that  it  bleeds  easily,  it  resembles  an  ulcerated 
surface.  For  this  reason  it  is  often  described  as  "ulceration "  of  the 
cervix,  but  it  is  no  more  an  ulceration  than  is  the  inflamed  mucous 
membrane  of  the  conjunctiva.  By  ulceration  we  understand  a  destruction 
and  loss  of  tissue.  The  epithelium  and  subepithelial  tissue  may  be  de- 
stroyed as  an  immediate  result  of  injury  during  labour  ;  but  the  raw-look- 
ing surface,  appearing  secondary  to  and  also  independent  of  lacerations 
(see  Catarrh  in  Nulliparse),  is  not  an  ulcerated  surface,  and  should  there- 
fore not  be  treated  as  such. 

For  the  appearance  presented  by  the  various  forms  of  laceration  when 
seen  in  the  speculum,  the  student  should  compare  Fig.  173  and  Fig.  174. 
The  difference  between  the  colour  of  the  everted  cervical  mucous  mem- 
brane and  that  of  the  vagina  is  represented  in  Plate  VIII.,  Figs.  1  and  2. 
A  beautiful  series  of  chromo-lithographs  is  appended  to  Munde's  article 
(Am.  Jour,  of  Obst.,  Jan.,  1879),  which  illustrates  the  various  degrees  of 
laceration.  The  most  complete  series  is  in  Nieberding's  pamphlet  which 
gives  representations  of  the  cervix  uteri  before  and  after  parturition,  both 
in  prirniparse  and  multipart  ;  the  colouring,  however,  is  unnatural. 

The  microscopic  changes  which  produce  the  appearance  simulating 
ulceration  will  be  described  under  Cervical  Catarrh. 

The  tenacula  are  a  valuable  adjunct  in  examination  Avith  the  speculum. 
If  we  place  one  in  the  anterior  and  one  in  the  posterior  lip,  and  roll  these 
in  on  one  another,  the  raw-looking  surface  will  in  many  cases  disappear. 
This  easily  demonstrated  fact  had  not  been  recognized  till  Emmet  drew 
attention  to  it,  and  based  on  it  the  operation  which  will  be  always  associ- 
ated with  his  name.  By  thus  rolling  the  lips  inwards,  we  restore  the 
laceration  and  see  the  extent  of  it  so  as  to  judge  of  the  possibility  of  ap- 
proximating the  lips  with  sutures. 

We  need  not  remind  the  student  that  he  must  not  be  satisfied  with 
finding  a  laceration  of  the  cervix,  however  striking  it  may  appear  in  the 


AFFECTIONS  OF  THE  UTERUS.  283 

speculum.  The  bimanual  examination  should  be  done  with  all  the  greater 
care,  to  ascertain  that  there  is  not  also  present  cellulitis  or  subinvolution 
of  the  uterus. 


TREATMENT. 

Treatment,  to  be  scientific,  must  be  based  on  correct  pathology.  This, 
we  think,  is  the  strongest  argument  in  favour  of  the  reasonableness  of 
Emmet's  operation. 

Like  every  new  method  in  medicine  and  surgery,  the  operation  has 
been  performed  in  numbers  of  cases  where  it  was  not  called  for.  After 
the  student  has  been  in  practice  he  will  find  cases  of  chronic  metritis  (or 
subinvolution)  and  cellulitis  the  most  difficult  to  treat ;  hence  Emmet's 
operation  was  hailed  in  America  by  the  weary  and  baffled  gynecologist  as 
the  panacea  for  which  he  was  waiting.  This  abuse  of  the  operation  in 
America  is  one  reason  why  it  is  so  slow  in  finding  acceptance  in  this 
country.  In  Germany  it  has  been  taken  up  by  Breisky,  Spiegelburg,  and 
others.  Schroeder's  operation  for  cervical  catarrh  is  practically  a  bilateral 
Emmet's  operation  combined  with  excision  of  the  cervical  mucous  mem- 
brane. . 

The  stitching  up  of  the  laceration  immediately  after  parturition  was 
first  performed  by  Fallen  of  New  York.  Having  failed  to  check  by  the 
tampon  post-partum  hemorrhage  from  a  lacerated  cervix,  he  passed  Sims' 
speculum  and  sewed  up  the  laceration  with  silver-wire  sutures  ;  this 
checked  the  hemorrhage.  We  have  never  had  occasion  to  perform  the 
"immediate  "  operation  ;  injections  of  very  hot  water  have  always  sufficed 
to  check  hemorrhage.  Considering  the  liability  to  septic  inflammation  in 
the  puerperal  condition,  we  would  be  very  chary  about  operating  unless 
the  hemorrhage  were  considerable  and  not  diminished  by  hot  injections. 

The  paring  of  the  edges  of  an  old  laceration  and  uniting  of  them  with 
sutures,  we  shall  call  "Emmet's  operation,"  a  simpler  and  more  suggestive 
name  than  "Trachelorraphy." 

Indications  for  Emmet's  Operation. — In  the  treatment  of  lacerations,  as 
of  many  other  uterine  affections,  skill  may  often  be  shown  in  knowing  to 
leave  the  case  alone  rather  than  in  operating.  (See  Lee's  paper.) 

We  should  not  operate  : — 

1.  When  laceration,  however  well  marked,  has  produced  no  symptoms. 

2.  Where  chronic  pelvic  peritonitis  or  cellulitis  is  present. 

As  to  the  circumstances  in  which  an  operation  is  called  for,  Emmet 


284  MANUAL    OF    GYNECOLOGY. 

says,  "  in  every  instance  where  the  condition  is  evident,  and  where  en- 
largement of  the  uterus  still  remains,  or  where  the  woman  suffers  from 
neuralgia,  I  consider  an  operation  necessary,  notwithstanding  the  parts 
may  have  completely  healed."  As  he  ascribes  sterility  to  laceration,  he 
holds  this  also  as  an  indication  for  his  operation  in  certain  cases.  Second- 
ary catarrh  may  prevent  conception,  but  lacerations  are  so  common  in  the 
fertile  that  we  should  not  consider  them  a  cause  of  sterility. 

We  recommend  the  operation  in  cases  of  pronounced  eversion  of  the 
mucous  membrane  with  cervical  catarrh,  with  or  without  subin volution. 
Subinvolution  often  disappears  after  the  operation,  but  we  cannot  say  that 
this  is  due  to  the  closure  of  the  laceration  ;  involution  is  stimulated  by 
every  operation  on  the  cervix  (v.  Chronic  Metritis). 

Preliminaries -to  the  Operation. — The  patient  should  use  warm  water  in- 
jections for  some  weeks  previous  to  the  operation,  and  apply  a  blister  if 
there  be  any  indication  of  cellulitis.  Emmet  lays  great  stress  on  this 
preparatory  treatment,  and  says  that  we  should  not  operate  so  long  as 
there  is  any  tenderness  on  pressure  in  the  fornices.  He  further  recom- 
mends, in  cases  where  the  cervix  is  thickened  and  the  mucous  follicles 
enlarged,  scarification  of  the  cervix  and  painting  with  iodine  or  tannin 
and  glycerine. 

The  Operation. — The  following  instruments  are  required : — 

Vaginal  douche, 

Sims  speculum, 

Volsella, 

Tenacula, 

Rubber  ring, 

Bistoury  and  scissors, 

Dissecting  forceps, 

Short  needles  (Fig.  112),  straight  and  curved, 

Needle-holder, 

Medium  silver  wire. 

The  patient  is  placed  under  chloroform  in  the  lithotomy  posture  (in 
the  semiprone  posture  by  Emmet,  but  this  does  not  give  the  operator  so 
much  room) ;  the  sacral  segment  is  drawn  back  with  the  speculum  by  an 
assistant,  and  the  cervix  is  laid  hold  of  with  the  volsella  and  drawn  down. 
Draw  the  edges  of  the  laceration  together  with  the  tenacula  to  see  how 
much  tissue  must  be  pared  from  the  edges  of  the  cleft  to  allow  it  to  be 
sewed  up,  and  then  proceed  to  operate.  Slip  the  rubber  ring  over  the 


AFFECTIONS    OF    THE    UTERUS. 

volsella  on  to  the  cervix  and  place  it  so  as  to  constrict  the  base  :  this  pre- 
vents bleeding  and  thus  allows  the  operator  to  see  tint  ilie  edges  are  com- 
pletely pared,  which  is  essential  to  union  of  the  raw  surfaces.  Wash  out 


Fii,'.   175. 
Operation  for  l.ioeniterl  cervix  :  a  6.  extent  of  .IrntKled  siirf.vo. 

the  vagina  with  carbolised  water.  When  possible,  continual  irrigation  i. 
kept  up  during  the  operation  ;  with  this,  the  india-rubber  ring  is  not  r  - 
quired,  as  the  stream  of  water  keeps  the  denuded  surface-  al\v;iys  clean. 
Now  pare  the  edges  of  the  laceration  with  the  scissors  or  knife  (Fig.  175)  : 


Extent  of  (lentl'leil  snrfnfv  nnd  course  nf   =  !;tnre-;  :ic. 


nler  1.  a.  :!.   1:   the  rnr.r-e  ,,f  nit-re   I  nl<.i:c  i-  ;n  !:--iit.-  1  !••,  '.  !!•  r-  <i.  I,  •  .  .1 


scissors  are  preferable,  because  they  cut  with  grenter  ruse  and  i"!]>i'lity 
With  long-bladed  scissors  we-  can  remove'  tlir  tissue  from  one  rdge  of  tin 
laceration  with  a  steady  clean  cut  right  into  the  angle  ;  Kmm<  t  l;iv<  gi-fu 


286 


MANUAL    OF    GYNECOLOGY. 


stress  on  the  removal  of  the  cicatricial  tissue  in  the  angle,  but  uses  the  bis- 
.toury  to  do  this.  When  the  laceration  is  bilateral  this  must  be  done  on 
both  sides.  Fig.  176  shows  the  extent  of  surface  denuded  by  Emmet  in 


Fig.  177. 
Mode  of  passing  sutures ;  a,  6,  denuded  surface  as  in  Pig.  175.    The  sutures  are  passed  in  order  as  numbered. 

a  case  of  bilateral  laceration.  Great  care  must  be  taken  to  leave  a  broad 
strip  (broader  than  represented  in  Fig.  176)  undenuded  in  the  middle  line 
to  form  the  walls  of  the  cervical  canal.  Now  introduce  the  sutures ;  these 


Appearance  of  cervix  when  sutures  twisted  up.    They  are  left  long  so  as  to  extend  to  vaginal  orifice  and 
are  removed  in  order  as  numbered. 

are  about  eight  inches  long,  so  that  both  ends  protrude  from  the  vagina, 
and  are  well  adapted  to  the  eye  of  the  needle  so  as  not  to  obstruct  its  pas- 
sage. Emmet  recommends  the  round  ndedle,  as  it  makes  a  smaller  hole 
and  is  therefore  followed  by  less  hemorrhage  ;  when  the  tissues  are  dense, 


AFFECTIONS    OF   THE    UTERUS.  287 

the  lance-shaped  point  perforates  more  easily.  Pass  the  sutures  as  in  Fig. 
177,  beginning  at  the  upper  part  of  the  wound :  each  is  drawn  half  through 
but  is  not  twisted  up  till  its  fellows  are  in  position,  as  it  is  sometimes 
necessary  (when  the  tissues  are  thick)  to  pass  the  needle  first  through 
one  lip  and  then  through  the  other ;  they  are  then  twisted  up ;  the  ends 
are  brought  out  at  the  vaginal  orifice,  tied  together,  and  wrapped  round 
with  a  piece  of  wadding  (Fig.  178). 

Emmet  cuts  the  sutures  short,  but  the  long  ends  facilitate  their  re- 
moval. No  special  regimen  is  required  afterwards,  the  diet  need  not  be 
restricted. 

Removal  of  Sutures. — The  stitches  are  removed  on  the  seventh  or  eighth 
day.  To  do  this  we  require  speculum,  wire-scissors,  rake  and  forceps. 
The  rake  is  almost  indispensable  in  removing  sutures  from  the  cervix  or 
vagina  ;  it  is  represented  and  described  at  Fig.  168.  The  sutures  are  re- 
moved from  above  downwards ;  if  we  reverse  the  order,  we  may  tear  the 
lower  portion  apart  in  removing  the  upper  sutures ;  if  the  surfaces  have 
not  entirely  united,  the  lower  sutures  should  be  left  in  for  a  few  days 
longer. 

The  cicatrix  does  not  cause  difficulty  in  subsequent  parturitions. 


CHAPTER  XXYIH. 

CHEONIC  CERVICAL  CATAEBH. 

LITERATURE. 

Barnes— Op.  cit.,  p.  530.  Bennett,  G.  H.—  Practical  Treatise  on  Inflammation,  Ul- 
ceration,  and  Induration  of  the  Neck  of  the  Uterus  :  London,  1845.  Clifton. 
Wing — Brit.  Med.  Journ  ,  March  16, 1875.  Duncan,  Matheics — Clinical  Lectures  : 
London,  1879.  p.  27.  Fischel—Wn  Be'tragzur  Histologie  derErosionen  der  Portio 
Vaginalis  Uteri:  Archiv.  f.  Gyn.,  Bd.  XV.,  Hft.  1.  Hatton— Dublin  Journal 
of  Med.  Science,  June  1,  1875.  Hennig — Der  Katarrh  der  inneren  weiblichen 
Geschlectstheile  :  Leipzig,  18G2.  Ileywood,  Smith — Obst.  Jo-rn.  of  Great  Brit- 
ain, 1876,  p.  304.  Ilildebi'andt — Volkmann's  Samralung  klin.  Vortrage  :  Leipzig, 
1872,  No.  32.  Klotz — Gynakologische  Studien  iiber  die  pathologiechen  Veriinde- 
rung,  der  Portio  Vaginalis  Uteri :  Wien,  1879.  Huge  and  Veit  — Zeitschrif t  f. 
Geb.  u.  Gyn.,  Bd.  II.,  S.  415.  Schroeder—Op.  cit.,  S.  122.  Thomas— Op.  cit., 
pp.  275  and  336. 

Acute  catarrh  of  the  cervix  is  known  to  us  only  as  part  of  a  general 
catarrh  affecting  both  body  and  cervix,  and  will  be  described  under  Acute 
Endometritis. 

Chronic  catarrh  occurs  localised  in  the  cervical  mucous  membrane  ; 
it  is  a  very  common  condition  and  one  of  the  most  troublesome  which 
the  practitioner  has  to  treat. 

PATHOLOGY. 

The  mucous  membrane  of  the  cervical  canal  is  inflamed.  "When  the  os 
externum  has  been  lacerated,  the  lips  gape  and  the  mucous  membrane  is 
thus  everted  ;  on  bringing  the  margins  of  the  laceration  together,  this 
eversion  will  disappear.  Further,  there  are  granular  patches  with  irregu- 
lar outline  which  extend  beyond  the  limits  of  the  os  externum  ;  these 
have  a  red  appearance  similar  to  the  cervical  mucous  membrane,  and 
therefore  are  sharply  denned  from  the  paler  mucous  membrane  which 
covers  the  vaginal  portion  of  the  cervix. 


AFFECTIONS    OF    THE    UTERUS. 


1>S9 


Tliis  last  condition  was  till  late  years  Amorally  held  to  be  an  i;  ulcora- 
tion,"  and  is  still  described,  even  in  recent  English  works,  under  tliat 
name.  Tlie  term  should,  however,  "be  discarded  as  bused  on  an  erroneous 
pathology  and  suggesting  most  pernicious  treatment.  The  cause  of  the 
error  is  easily  explained  ;  a  raw-looking  granular  surface  was  seen  in  the 
speculum  :  the  raw  appearance  was  ascribed  to  the  loss  of  the  epithelium, 
and  this  supposition  was  supported  by  the  microscopic  examination  of 
specimens  taken  from  the  dead  body,  in  which  the  epithelium  had  been 
macerated  and  removed  ;  the  granular  points  were  supposed  to  be  the 
subjacent  papilla1  which  had  become  hypertrophied. 

Both  of  these  suppositions  have  been  shown  to  be  erroneous  by  the 
careful  investigations  of  Huge  and  Yeit,  who  examined  specimens  of  the 


(S.-hrur.lrr'l. 


so-call('d  ulcerations-  cut  fresh  from  the  living  subject:  they  demonstrated 
(1)  that  the  apparently  raw  surface  is  covered  with  epithelium.  '  -  >  that  the 
granular  points  are  new  formations  and  have  no  connection  with  the 
papillie  of  the  mucous  membrane. 

The  microscopic  appearance  of  the  mucous  membrane  described   by 
them   is  us   follows  :    The   surface   is  covered    with   a   single    layer  of    epi- 
thelium ;  the  cells  are  smaller  than   those  which   line  the   normal  cervical 
canal,  and  being-  narrow  and  long  have  a  palisade  like  arr.mgemenl  ;  ih- 
thin  layer  of  cells  allow  the   subjacent  vascular  tissue   to  shine   tlmm-h 
hence  the  rr(l,n>*x  of  color.      The  surface  is  further  thrown   into   mum  mus 
folds  producing  glandular  recesses   and    process!  s  :   tiiesc    processes   c:n 
the  i/r/nn/f'ir  appearance    of   the   sni'fare.      This   condition    i<   well   seel 
Plate  VIII.,  and  constitutes  the  s        f>'  erosion  :    \'\<_<.   1  shn 
sion  as  seen  in  the  speculum  :    l'"ig.   :*>   shows  a   microscopies 
same,  stained   with   carmine;  the   left   half  of   the  section   correspoi 
Yui,.  l.—l'.) 


290 


MANUAL    OF    GYNECOLOGY. 


the  deep  red  portion  of  Fig.  1,  the  right  half  to  the  paler  portion  outside 
of  this.  If  the  recesses  be  long  and  narrow,  the  surface  is  split  up  into 
distinct  papillae  ;  this  constitutes  the  papillary  erosion  (see  Fig.  179).  If 
the  ducts  of  the  glandular  recesses  become  obliterated,  the  secretion  will 
distend  the  gland  below  and  produce  retention-cysts  ;  these  will  increase 
in  size,  and  may  come  to  the  surface  and  burst.  Thus  there  is  formed  the 
follicular  erosion  (see  Fig.  180). 

The  raw-looking  surface  is  therefore  a  newly  formed  glandular  secreting 
surface,  resembling  in  structure  the  cervical  mucoiis  membrane.  This 
addition  to  the  extent  of  secreting  surface  increases  the  leucorrhoeal  dis- 
charge which  is  the  leading  symptom. 

These  observations  of  Ruge  and  Veit  have  been  confirmed  in  their 
essential  points  by  Fischel  and  other  observers ;  Fischel  considers  the  se- 
creting processes,  while  being  new  formations,  to  have  the  structure  of 
papillae  and  not  to  be  mere  foldings  of  the  mucous  membrane. 

While  there  is,  therefore,  no  disagreement  as  to  the  microscopical  ap- 
pearance of  the  so-called  "  ulcerations,"  the  origin  of  this  new  epithelial 
structure  is  disputed.  Huge  and  Veit  hold  that  this  single  layer  of  small 


Fig.  ISO. 
Follicnlar  form  of  eros'on  (Schroeder). 

cylindrical  cells  is  produced  by  proliferation  of  the  cells  of  the  deepest 
layer  of  the  rete  Malpighi,  while  those  of  the  superficial  layer  are  shelled 
off ;  the  appearance  seen  in  Fig.  180  favours  this  view.  It  will  be  observed 
also  that  they  regard  the  simple  follicular  and  papillary  "  ulcerations  "  as 
the  results  of  one  and  the  same  process,  viz.,  proliferation  of  epithelial 
cells.  On  the  other  hand,  those  red  patches  are  generally  continuous  with 
the  mucous  membrane  of  the  cervical  canal  and  resemble  it  in  their  micro- 
scopic structure  ;  it  is  therefore  much  more  probable  that  they  are  occa- 
sioned by  proliferation  of  the  epithelium  which  lines  the  cervical  glands,  lead- 
ing to  an  extension  of  the  glandular  surface  beyond  the  os  externum. 


AFFECTIONS    OF   THE    UTERUS. 


291 


Fischel  holds  that  there  is  not  only  the  proliferation  of  epithelial  cells,  but 
of  connective  tissue  ;  and  that,  according  to  the  preponderance  of  the  one 
over  the  other,  the  follicular  or  papillary  forms  are  produced. 

This  description  of  the  microscopic  changes  makes  it  evident  that  the 
process  is  not  one  of  "  ulceration  ; "  and  this  term  should,  therefore,  be 
abandoned.  "  Ectropium  "  or  "  Eversion  of  the  mucous  membrane  "  de- 
scribes the  condition  in  its  relation  to  laceration,  but  does  not  describe 
the  extension  of  the  secreting  surface  beyond  the  oa  externum  ;  the  term 
is  preferable  to  "  ulceration,"  as,  at  least,  it  is  not  misleading.  Thomas 
describes  these  conditions  under  the  name  of  "  Granular  and  Cystic  De- 
generation of  the  Cervix  Uteri."  This  term  is  based  on  the  naked  eye 
appearance  of  the  cervix,  and  conveys  no  idea  as  to  the  pathological  change 
which  takes  place.  Under  granular  degeneration,  he  describes  the  papil- 
lary form  ;  under  cystic  degeneration,  the  follicular.  As  we  are  not  in  a 


True  ulceration  of  the  cervix.  At  the  sides  of  diagram  is  seen  the  normal  epithelium,  which  is  prolonged 
in  processes,  e  p,  between  the  connective  tissue  papilla; ;  e,  is  superficial  layer  of  squamotis  epithelium  re- 
duced to  a  thin  layer  at «' ;  c  t,  tissue  of  mucosa  infiltrated  with  small  cells ;  6  r,  blood-vessels  surrounded 
by  small-celled  infiltration.  (PischeL) 

position  to  introduce  a  term  based  on  pathology,  it  is  preferable  to  desig- 
nate it  according  to  its  symptom  as  Cervical  Catarrh.  The  red  patches 
which  lie  outside  the  os  externum  we  shall  speak  of  as  "  catarrhal 
patches." 

Sometimes  a  true  ulcerated  process— destruction  of  epithelium  with 
inflammation  of  connective  tissue — does  occur  ;  such  a  condition  is  repre- 
sented in  Fig.  181. 

Along  with  those  changes  in  the  mucous  membrane,  chronic  inflam- 
matory changes  occur  in  the  other  tissues  of  the  cervix.    There  is  increased  I 
formation  of  connective  tissue,  which  produces  antero-posterior  thickening, 
and  sometimes  elongation.     The  secretion  in  the  obstructed  glands  be- 
comes inspissated,  and  hence  the  retention  cysts  are  felt  as  firm  pea-like 


292  MANUAL    OF    GYJSTECOLOGY. 

bodies — Ovula  Nabothii — in  the  substance  of  the  cervix  or  projecting 
from  it ;  or  their  contents  may  suppurate  and  form  small  abscesses.  As 
there  are  no  racemose  glands  on  the  vaginal  portion  beyond  the  limits  of 
the  os  externum  (see  Histology  of  Normal  Cervix,  p.  19),  these  ovula  Na- 
bothii must  be  produced  from  the  glands  of  the  mucous  membrane  of  the 
cervical  canal  or  from  the  newly  formed  glandular  tissue.  Fritsch  draws 
attention  to  the  fact  that  the, glands  of  the  cervix  are  enormously  hyper- 
trophied  during  pregnancy,  so  that  the  cervix  becomes  almost  a  glandu- 
lar organ  ;  the  persistence  of  this  condition  after  the  puerperium  may 
explain  the  increased  glandular  formation  which  is  described  above  as  the 
chief  pathological  element  in  cervical  catarrh. 

Sometimes  we  find  a  single  large  cyst  in  the  cervix,  due  to  obstruction 
of  the  mucous  glands.  When  it  is  in  the  substance  of  the  wall,  the  soft 
bulging  into  the  cervical  canal  and  the  accompanying  menorrhagia  may 
lead  one  to  suspect  commencing  sarcomatous  infiltration.  Puncturing 
with  a  trocar  removes  a  clear  or  straw-coloured  fluid,  rich  in  mucous  cor- 
puscles. We  have  seen  a  cyst  of  such  a  size  as  to  cause  serious  obstruc- 
tion to  labor  in  a  woman  who  had  had  a  succession  of  uncomplicated 
labours. 

The  microscopic  pathology  of  the  cervix  has  only  of  recent  years  been 
carefully  investigated,  and  there  are  many  points  on  which  definite  infor- 
mation has  not  as  yet  been  obtained.  The  following  is  a  brief  summary 
of  the  pathological  changes  described,  which  are  best  understood  by  com- 
parison with  the  microscopic  structure  of  the  normal  vaginal  portion. 

NORMAL  CONDITION. — The  vaginal  portion  is  covered  on  its  vaginal  sur- 
face with  many  layers  of  squamous  epithelium,  resting  on  papillae  of  con- 
nective tissue  ;  there  are  no  mucous  follicles.  The  cervical  canal  is  lined 
with  a  single  layer  of  cubical  epithelium  (ciliated  only  on  the  free  surface), 
folded  so  as  to  form  shallow  recesses  which  do  not  branch  ;  there  are 
racemose  mucous  glands,  which  have  branching  ducts.  The  substance  of 
the  cervix  is  made  up  of  connective  tissue. 

PATHOLOGICAL  CHANGES. — These,  according  to  the  extent  and  duration 
of  the  process,  affect  the  three  elements— epithelium,  glands,  connective 
tissue. 

The  epithelium  of  the  cervical  canal  may  be  simply  exposed  (ectropium 
after  laceration),  or  it  may  be  inflamed.  When  inflamed,  the  folding  of 
the  mucous  membrane  is  greatly  increased  so  that  the  surface  has  a  papil- 
lary or  granular  appearance.  Further,  this  inflamed  mucous  surface  may 


AFFECTIONS  OF  THE  UTERUS.  293 

be  found  extending  beyond  its  normal  limit  (the  os  externum)  in  the  form 
of  red  patches  (catarrhal  patches)  which  are  smooth  or  granular. 

The  glands  hypertrophy,  and  new  glands  form  as  the  result  of  the 
proliferation  of  epithelium  described  above.  The  openings  of  the  glands 
are  at  first  restricted  to  the  area  covered  with  a  single  layer  of  cubical 
epithelium,  but  their  branching  ends  extend  below  the  limiting  surface  of 
stratified  squamous  epithelium.  Their  ducts  become  obstructed,  and  re- 
tention cysts  form  not  only  on  the  red  patches  but  also  underneath  the 
adjacent  apparently  normal  vaginal  mucous  membrane.  They  may  remain 
as  little  nodules  in  the  mucous  membrane,  or  may  come  to  the  surface 
and  burst ;  in'  ihe  latter  case  the  cubical  epithelium  and  papillae  on  the 
inner  wall  of  the  cyst  are  exposed  and,  being  now  on  a  free  surface,  pro- 
liferate. When  the  glands  are  the  special  seat  of  the  pathological  changes, 
the  whole  substance  of  the  cervix  is  converted  into  a  cystic  mass. 

The  connective  tissue  always  increases  in  amount,  specially  when  the 
process  is  chronic.  This  increase  constitutes  the  "  areolar  hyperplasia  " 
of  Thomas. 

ETIOLOGY. 

The  most  important  cause  is,  undoubtedly,  the  injury  of  the  cervix 
produced  in  parturition;  hence  cervical  catarrh  is  common  in  parous 
women.  How  this  injury  produces  the  inflammatory  condition  is  a  dis- 
puted point.  Emmet  refers  it  immediately  to  the  laceration,  and  holds 
that  the  exposure  of  the  mucous  membrane  to  friction  against  the  vaginal 
walls  leads  to  irritation  and  inflammation  ;  but  we  frequently  see  cases  of 
well-marked  lacerations  without  consequent  cervical  catarrh.  It  is  ad- 
mitted by  all  that  the  existence  of  kcerations  greatly  favours  the  develop- 
ment of  catarrh. 

Other  less  important  causes  are  the  spread  of  inflammation  from  the 
vagina  upwards  (vaginitis,  which  may  be  simple  or  gonorrhoeal),  and  from 
the  endometrium  downwards.  The  latter  is  favored  by  the  fact  that  the 
discharges  from  the  endometrium  necessarily  flow  over  the  cervix  and 
irritate  it. 

Cervical  catarrh  is  the  most  frequent  complication  of  retroflexion  of 
the  uterus.  The  flexion  favours  gaping  of  the  lacerated  cervix  and  pro- 
duces passive  congestion  of  the  cervical  tissuea 


294  MANUAL    OF    GYNECOLOGY. 

SYMPTOMS. 

These  are — Leucorrhcea ; 

Pain  in  back  and  loins,  increased  on  exercise  ; 

Irregular  menstruation  ; 

Sterility. 

Leucorrhoea  is  the  prominent  symptom.  Under  normal  conditions  the 
secretion  from  the  mucous  membrane  of  the  uterus  and  cervix  is  not  suffi- 
cient to  attract  attention ;  when  it  is  excessive,  it  is  termed  leucorrhoea 
(AeuKo's,  white,  pew,  to  flow),  or  in  popular  language  "  whites."  A  transient 
leucorrhcea  from  the  cervix  and  uterus  occurs  before  and  after  the  men- 
strual flow ;  this  is  a  hyper-secretion  due  to  temporary  congestion. 

The  secretion  from  the  glands  of  the  cervical  canal  is  clear  and  viscid, 
resembling  unboiled  white  of  egg.  It  becomes  of  an  opaque  white  when 
mucous  corpuscles  are  abundant,  yellowish  when  pus  corpuscles  are 
present.  Frequently,  it  is  tinged  with  blood  from  the  blood-vessels  of  the 
newly  formed  vascular  tissue. 

Pain  in  the  back  and  loins  is  present,  as  in  all  uterine  disease.  It  is 
aggravated  on  active  exercise,  such  as  walking  and  riding,  or  whatever 
causes  friction  of  the  cervix  against  the  vaginal  walls.  Pain  on  coitus  is 
sometimes  present. 

Menstruation  is  irregular,  and  often  increased  in  quantity ;  this  is 
probably  due  to  extension  of  inflammation  upwards  to  the  endometrium. 
We  must  take  care  not  to  mistake  leucorrhcea  tinged  with  blood  for  the 
regular  menstrual  flow. 

Sterility  is  often  present.  In  nulliparse  with  a  small  os  externum,  the 
plug  of  mucous  in  the  cervical  canal  is  often  an  effectual  bar  to  conception. 
In  multiparse,  we  have  seen  conception  take  place  even  though  there  was 
a  deep  laceration  and  well-marked  catarrh  ;  the  presence  of  catarrh, 
however,  though  not  an  obstacle  to  conception,  greatly  diminishes  its 
probability. 

PHYSICAL   SIGNS. 

On  vaginal  examination,  the  condition  of  the  cervix  is  found  to  vary 
according  as  the  patient  is  nulliparous  or  multiparous  and  the  disease  of 
long  or  short  duration.  In  a  nullipara,  the  cervix  feels  puffy  and  large, 
the  margins  of  the  os  soft  and  velvety  (when  there  is  eversion  with  ex- 
tension of  catarrhal  area  beyond  the  os  externum)  ;  or  the  os  and  cervix 


PLATE  Vlfl 


EROSION  AND  LACKS  AT  107?  OF  CERVIX  (RrGEAXn  VKIT). 

H.BENCKE.UITH.  N.  Y. 


AFFECTIONS  OF  THE  UTERUS.  295 

are  apparently  normal  but  movement  causes  pain  (when  the  catarrhal  area 
does  not  extend  beyond  the  os  externum).  In  a  multipara,  the  existence 
of  a  laceration  must  first  be  determined  and  the  extent  of  it  noted ;  the 
margins  of  the  os  are  soft  and  velvety,  and  pea-like  nodules  (Nabothian 
follicles)  are  felt  on  and  sometimes  round  them  ;  polypoidal  projections 
may  be  present  and,  more  rarely,  the  cervix  is  converted  into  a  mass  of 
cysts  ;  the  os  is  usually  gaping  so  that  the  finger  can  be  passed  into  the 
cervical  canal,  where  the  mucous  membrane  has  an  irregular  surface  and 
is  often  thrown  into  longitudinal  ridges. 

The  speculum  is  now  employed  ;  its  use  must  always  be  preceded  by 
a  careful  examination  with  the  finger  to  ascertain,  when  laceration  is 
present,  the  undisturbed  relations  of  the  lips  of  the  cervix.  Neither 
finger  nor  speculum  alone  is  sufficient,  we  must  employ  both,  and  learn 
to  associate  what  is  felt  by  the  finger  (e.g.,  lacerations,  velvety  mucous 
membrane,  pea-like  follicles)  with  what  is  seen  with  the  speculum.  The 
superiority  of  the  Sims  speculum  for  examination  is  very  marked,  as  it 
exposes  the  lip  of  the  cervix  without  disturbing  the  relations. 

In  a  nullipara,  we  see  the  os  apparently  normal  but  with  a  tenacious 
plug  of  mucus  projecting  through  it ;  or  there  may  be  red  catarrhal 
patches  such  as  are  represented  in  Plate  VIII. ,  Fig.  1,  which  shows  very 
well  the  contrast  between  the  appearance  of  these  patches  and  the  sur- 
rounding mucous  membrane  ;  no  chromo-lithograph,  however,  perfectly 
displays  the  natural  colours. 

In  a  multipara,  a  laceration  is  sometimes  evident.  Oftener  it  escapes 
recognition  ;  the  os  appears  to  be  wide  and  unfissured,  while  on  both  lips 
there  is  a  red  velvety  surface  (Plate  VHL,  Fig.  2)  ;  if,  now,  tenacula  be 
fixed  in  the  gaping  lips  and  these  rolled  in  on  one  another,  the  red 
surfaces  will  disappear  and  a  bilateral  laceration  become  evident  Some- 
times white  cicatricial  tissue  indicates  the  situation  of  the  laceration. 
Though  the  lips  are  thus  approximated,  a  red  surface  is  often  visible  be- 
cause the  catarrhal  area  has  spread  beyond  the  os  externum.  The  ob- 
structed Nabothian  follicles  appear  as  bluish-red  projections  from  the 
mucous  membrane  ;  occasionally  they  appear  as  small  polypi. 

DIAGNOSIS   AND   DIFFERENTIAL   DIAGNOSIS. 

The  diagnosis  between  cervical  and  vaginal  catarrh  is  made  clear  by 
using  the  speculum,  for  we  see  in  the  former  case  the  leucorrhoaa  coming 


296  MANUAL    OF    GYNECOLOGT. 

from  the  cervix  and  having  the  character  above  described.  Should  the 
discharge  not  be  profuse  enough  to  be  seen  with  the  speculum,  we  may 
employ  the  method  recommended  by  Schultz  for  diagnosing  between 
uterine  and  vaginal  catarrh.  The  vagina  is  washed  out  in  the  evening, 
and  a  tampon  soaked  in  a  solution  of  tannin  is  placed  against  the  os 
externum  ;  in  the  morning  the  tampon  is  removed  through  the  speculum, 
and  we  note  the  quantity  and  character  of  the  discharge  which  has  ac- 
cumulated above  it. 

The  diagnosis  between  cervical  catarrh  and  endometritis  is  difficult, 
and  in  many  cases  cannot  be  made ;  when  cervical  catarrh  is  present,  we 
cannot  be  positive  that  there  is  not  some  endometritis  as  well.  Increase 
in  the  length  of  the  uterine  cavity  (especially  with  tenderness  or  irregu- 
larities of  the  mucous  membrane),  ascertained  by  the  sound,  indicates 
endometritis.  When  the  cervix  is  much  thickened  and  indurated,  we  may 
suspect  the  commencement  of  malignant  disease  ;  this  will  be  considered 
under  Carcinoma  of  the  Cervix. 

PROGNOSIS. 

In  this  we  must  consider  the  constitutional  health  of  the  patient,  the 
duration  of  the  symptoms,  and  the  extent  to  which  the  tissues  are  affected. 
According  to  Thomas,  the  prognosis  is  less  favourable  when  there  is  con- 
siderable secretion  of  mucus  with  little  apparent  "  granular  degeneration." 
The  practitioner  will  often  find  that  cases  of  cervical  catarrh  have  already 
passed  through  several  hands,  and  he  should  therefore  be  on  his  guard  in 
offering  hopes  of  speedy  cure. 

TREATMENT. 

In  the  first  place,  special  attention  must  be  given  to  the  patient's  gen- 
eral health  ;  if  we  trust  to  local  treatment  alone,  we  shall  often  be  disap- 
pointed. "We  should  recommend  change  of  air  and  light  nourishing  food. 
A  certain  amount  of  exercise  is  valuable  ;  but  too  much  of  it,  specially  of 
riding,  is  injurious.  Tonics  (such  as  arsenic,  quinine,  and  iron)  are  useful. 
Disturbances  of  the  digestive  system,  which  are  frequent  in  chronic  cases, 
must  be  treated  as  each  case  indicates.  Complete  rest  from  sexual  activity 
is  advisable  ;  this  can  often  be  secured  by  recommending  that  the  patient 
go  away  from  home  for  a  time. 

Cervical  catarrh  is  in  some  cases  only  a  local  manifestation  of  a  consti- 
tutional state  such  as  tuberculosis  or  anasmia. 


AFFECTIONS    OF    THE    UTERUS.  297 

The  local  treatment  varies  according  as  the  patient  is  nulliparous  or 
nmltiparous.  In  both  cases  we  must  be  prepared  to  carry  out  a  system  of 
treatment  which  lasts  for  weeks. 

1.  In  nulliparce  we  begin  with  a  course  of  vaginal  injections  of  warm 
water.  They  are  used  freely,  from  ten  minutes  to  a  quarter  of  an  hour, 
every  night.  To  the  simple  water,  sulphate  of  zinc  (  3  j.  to  the  pint),  sul- 
phate of  alumina  or  sulphate  of  copper  (  3  ij.  to  the  pint)  may  be  added. 

If  the  os  be  narrow,  as  it  usually  is,  it  is  good  to  notch  it  bilaterally 
with  the  scissors.  This  acts  beneficially  in  three  ways — by  allowing  the 
mucus  to  escape  freely,  by  opening  up  the  canal  so  as  to  allow  of  further 
applications,  by  favouring  the  occurrence  of  pregnancy. 

When  catarrhal  patches  are  present  round  the  os,  or  when  we  find  that 
the  secretion  continues  copious  in  spite  of  the  frequent  injections,  we 
must  make  a  local  application  to  the  mucous  membrane.  Of  applications 
the  best  are  iodine  (the  tincture  or  the  strong  liniment)  and  carbolic  acid, 
the  former  in  milder  and  the  latter  in  more  severe  cases.  The  liquor  hy- 
drargyri  pernitratis  is  recommended  by  Hey  wood  Smith,  and  chromic  acid 


Fig.  182. 
Forceps  dressed  with  cotton  wadding. 

is  much  praised  by  de  Sinety.  In  making  these  applications  we  proceed 
as  follows :  the  mucus,  which  would  prevent  the  action  of  the  medicament 
on  the  mucous  membrane,  is  first  thoroughly  removed  by  the  forceps 
dressed  with  cotton- wool,  as  represented  at  Fig.  182.  A  second  pair  of 
forceps,  covered  merely  with  a  film  of  cotton  wadding,  is  now  dipped  in 
the  medicament  and  applied  to  the  surface.  Should  the  canal  be  narrow, 
a  sound  dressed  as  for  endometric  applications  (see  Fig.  190)  is  preferable. 
Care  is  taken  that  there  be  no  free  drop  of  the  solution  on  the  cotton-wool, 
which  might  fall  on  the  vaginal  mucous  membrane  ;  after  the  application 
is  made,  a  jet  of  water  is  thrown  on  the  cervix  to  wash  off  any  superfluous 
acid  and  a  pledget  of  cotton  wadding  with  glycerine  is  placed  below  the 
cervix. 

Earely  in  nulliparae  is  the  pathological  process  so  extensive  as  to  require 
operative  means  for  removing  cervical  tisstie. 

2.  In  MuUiparce.-H.ei-e  the  cervical  catarrh  is  usually  associated  with 


298  MANUAL    OF    GYNECOLOGT. 

other  conditions — retroflexion,  subinvolution,  and,  especially,  marked 
laceration  of  the  cervix.  The  first  treatment  indicated  is  to  diminish  the 
passive  congestion  of  the  cervix  by  hot  water  injections  and  the  use  of  the 
glycerine  plug.  The  latter  is  prepared  as  already  described  (p.  196),  and 
should  be  renewed  daily.  The  patient  can  introduce  it  herself  with  Barnes' 
speculum  (Fig.  183).  A  simpler  means  is  to  draw  the  string  through  a 
piece  of  glass  tubing,  and  to  keep  it  taut  with  the  finger  on  the  end  of  the 
tube  till  the  plug  is  carried  into  the  roof  of  the  vagina  ;  then  the  finger  is 
removed  and  the  tube  is  slipped  out  over  the  string.  If  the  uterus  be  re- 
troflexed,  it  should  be  replaced  and  kept  in  position  by  a  pessary.  Even 
where  it  is  not  displaced,  a  pessary  is  often  useful  in  lifting  the  uterus  up- 
wards in  the  pelvis  and  diminishing  passive  congestion.  In  cases  where 
there  is  a  distinct  laceration  of  the  cervix,  and  specially  where  the  catarrhal 


Fig.  183. 

Barnes'  speculum  for  introduction  of  medicated  cotton-wool  into  the  vagina  (Barnes). 

patches  can  be  made  to  disappear  by  rolling  the  lips  inwards  on  each  other, 
Emmet's  operation  is  indicated. 

Local  depletion  by  scarification  or  leeches  was  formerly  much  employed, 
but  is  going  out ;  its  effects  are  only  transitory.  Scarification  is  done 
best  through  the  Fergusson  speculum,  and  with  a  lancet-shaped  bistoury ; 
a  number  of  small  punctures  are  made,  from  a  quarter  to  half-an-inch  in. 
depth.  Leeches  are  applied  as  follows  :  Fergusson's  speculum  is  passed ; 
a  pledget  of  lint,  with  string  attached,  is  placed  in  the  cervical  canal  to 
prevent  their  crawling  upwards  into  the  uterine  cavity  ;  a  little  blood  is 
drawn  by  superficial  scratches  and  three  or  four  leeches  thrown  into  the 
speculum,  and  pushed  up  towards  the  cervix  with  a  pledget  of  cotton 
wadding.  We  must  watch  the  speculum  lest  the  leeches  slip  out ;  after 
the  spe«ulum  and  leeches  are  removed,  the  vagina  is  douched  with  a  tepid 
injection  of  carbolised  water. 

Scarification  is,  however,  useful  for  another  object.  When  there  are 
hard  knobby  retention  cysts  producing  irritation  by  the  pressure  of  their 
contents,  the  puncturing  of  these  diminishes  the  chronic  inflammation. 
When  these  cysts  project  as  small  polypi,  they  are  easily  snipped  off. 


AFFECTIONS    OF    THE     L'TKKCS. 

In  very  chronic  cases,  the  only  remedy  is  the  destruction  of  the  dis- 
eased glandular  tissue— just  as  in  tonsillitis  we  excise  the  tonsils.  This 
has  been  done  by  the  application  of  strong  nitric  acid  or  the  cautcrv  ;  but 
the  use  of  the  curette  or  knife  is  a  much  more  effective  and  safe  method 
than  any  process  of  cauterisation.  Thomas  commends  the  steel  curette 
for  the  removal  of  the  diseased  glands  ;  it  is  applied  ''so  forciblv  as  to  re- 
move the  arbor  vihe  and  mucous  glands  from  the  os  internum  to  the  os 
externum.  Sometimes  a  second  operation  in  two  or  three  weeks  after  the 
first  has  been  necessary,  and  sometimes  even  a  third." 

Schroeder  uses  the  knife,  and  operates  as  follows.     The  cervix  is  laid 


hold  of  with  two  volsella,  one  on  each  lip.  and  drawn  downwards.  It  is 
divided  laterally  as  far  as  the  fornix  witli  the  scissors,  so  us  to  form  an 
anterior  and  a  posterior  lip.  which  arc  separate  as  far  as  the  v;ii  inal  roof 
(Fig.  IS-h.  A  transverse  incision  (seen  in  section.  ;it  -/.  Fi  •..••.  \*~»  is  made 
across  the  base  of  the  anterior  lip,  dividing  the  whole  thickm  -sot  the 
cervical  mucous  membrane.  He  next  pieces  the  point  ot  the  lip  at  <. 
pushing  the  knife  in  the  direction  //  h  till  it  reaches  the  CIM-V-,  incision  a  :  he 
carries  the  blade  outwards  first  to  one  side  and  then  to  the  othi  r.  so  that 
all  outside  of  the  line  n,  h  i:  is  cut  away.  The  Map  of  cer\i\  is  no\\  turned 
in.  and  stitched  as  in  Fig.  IS,").  'I'he  advantage  claimed  for  this  method 
of  ope  rat  ing  is  that,  the  degenerated  cervical  mucous  membrane  is  replaced 
bv  vaginal  mucous  membrane,  which  shows  no  tendency  to  d.  •  .  m-rite. 
Schroeder  has  operated  thus  more  than  three  hinidtvi  and  titt;.  limes 
(two  deaths),  and  with  very  good  results  a.s  to  the  cure  of  the  citarrh. 


CHAPTER  XXIX. 
ENDOMETKITIS. 

LITERATUKE. 

AttJull— On  Endometritis  :  Dublin  Journ.  of  Med.  Sci.,  Jan.,  1873.  Barnes — Op.  cit, 
p.  530.  Braun,  Carl— Therapie der  Me;ritis  und  Endoroetritis,  etc.:  Wiener  med. 
Wochenschrift,  1873,  Nos.  39-43.  De  Sinety— Gynecologic,  p.  327:  Paris,  1879. 
Guerin — De  la  Metrite  aierue:  Annales  de  Gynecolog.,  Juillet,  1874;  and  Arch, 
de  Tocologie,  July,  1877.  Hennig—Der  Katarrh  der  inneren  weiblichen 
Geschlechtstheile :  Leipsig,  1862.  Klob — Op.  cit.,  S.  211.  Olshausen — Uebcr 
chronische  hyperplasirende  Endometritis  des  Corpus  Uteri :  Archiv.  f .  Gynakolo- 
gie,  Band.  VIII.,  Heft  1.  Playfair— Intra-uterine  Medication  :  Brit.  Med.  Journ., 
December,  1869;  ibid.,  March,  1880;  Lancet,  January  and  February,  187#. 
Recamier — Union  Med.  de  Paris,  1850,  Juin  1-8.  Routh — On  Fundal  Endome- 
tritis :  Obst.  Trans. ,  Vol.  XII. ;  Cases  of  Menorrhagia  Treated  by  Injections,  etc. : 
Obst.  Trans.,  Vol.  II.  Schroeder—Op.  cit.,  S.  108.  Simpson,  Sir  J.  F.— Op. 
cit.,  p.  736.  Smith,  Tyler — Pathology  and  Treatment  of  Leucorrhoea ;  Lon- 
don, 1855.  Thomas— Op.  cit;  p.  268. 

INFLAMMATORY  action  may  affect  the  peritoneal  covering,  the  muscular  sub- 
stance, or  the  mucous  membrane  of  the  uterus,  producing  perimetritis, 
metritis,  or  endometritis.  Usually  we  find  more  than  one  of  these  condi- 
tions present  at  once,  as  the  inflammatory  action  is  rarely  limited  to  one 
of  these  coats.  Perimetritis  is  only  a  part  of  pelvic  peritonitis,  under 
which  head  it  has  already  been  considered. 

We  now  consider  inflammation  limited  to  the  mucous  membrane  of 
the  uterus — endometritis,  which  may  be  acute  or  chronic. 

DEFINITION. — Inflammation  of  the  mucous  membrane  of  the  uterus. 

SYNONYMS. — Uterine  catarrh,  internal  metritis. 

PATHOLOGY. 

In  acute  endometritis  both  body  and  cervix  are  involved,  and  usually  the 
underlying  muscular  coat  also.  The  mucous  membrane  is  swollen  and 


AFFECTIONS    OF    TIIE    UTERUS.  ,",0l 

soft,  and  covered  with  red  stained  mucus  or  creamy  pus.  Extravasations 
of  blood  are  present  as  red  streaks  or  patches.  These  changes  are  nut  so 
marked  in  the  cervical  mucous  membrane  as  in  that  of  the  body;  the 
vaginal  portion  has  the  same  appearance  as  during  pregnam-v.  being  soft 
and  swollen  and  showing  round  the  os  red  eatarrhal  patches. 

Tiie  ciliated  epithelium  is  destroyed,  and  sometimes  casts  of  the  epi- 
thelium of  the  glands  are  found  in  the  discharge  <Schroeder>.  The  secre- 
tion is  at  first  serous,  then  purulent. 

In  chronic  endometritis,  the  mucous  membrane  is  hypertrophied  and 
marked  with  patches  of  old  extravasation. 

The  microscopic  appearances  vary  with  the  structures  which  are  prin- 
cipally affected.  Our  knowledge  upon  this  subject  is  principa'.lv  derived 
from  the  examination  of  the  portion  of  mucous  membrane  removed  by  the 
curette.  We  can  distinguish  three  pathological  types  according  to  tL  tis 


sue  chiefly  involved.      In  the-  tir-t.  tin1  gl.m  1-  are   hypertrophii   1  :    in    the 
second,  the  vessels  are  dilated  and  enlarged  :  in   the   thir  1.     n  iVi  ri  •  - 

tiated  embryonic  tissue  is  produced.      We  mu<t    remember.  hn1  evt  r.  1 
in  no  case  is  one  structure  alone  affected  ;   then-  is  no   hard    an  1   fi-t 
between  the  different  processes.      For  the  fullowir.Lr  d>  script!"!]  \\,    :uv  in- 
debted to  tlie  researches  of  (  )l>lruis«'ii.  Carl  IJuire.  an  1  1  >t    > 

According  to  Schro.  ler's  clinical  observations.  tii«   :.  icr-  -  invi -ti- 

gation  .  if  which  lias  he-n  made  by  \ln-j>  .  the  mo-i  fr«  ou.  ?.t   c   ;.  i;; .    M  i-  a 
hypertrojiliy  of  the  gl  in  Is.      In  some  ca-  -  th<  y  are  so  :::ii>-i: 
that   tiie    granulations   :ipp,  ar   as   ma<-  -   of   ;-laiidiil  tr    !;--•:>.    : 
shown  by  the*  acoompanviniT  nV'ii'f'  fi'um  I V  Sin- ty  ( 1S|').      In   >;icli  u  IMII- 
dition.  tlie  chief  svmjitom  is  leiicorrho  a. 

Olshausen  lias  ilescril>e  1  very  carefully  the  clniigi  -  of  tlie  mu  •o;i-  im 
l.n'ano  in  cases  of  tlie   second  tvpe.  \\\  which   th«-   m  1;    -;•'"•! •' ••'•'••   i"   h- •:.   r- 
rhage.     The  mucous  membrane  is  hypertniphu-.l  to  thn-c  or  ;'«ur  t;m»  s  its 


302  MANUAL    OF    GYNECOLOGY. 

normal  thickness.  It  is  elevated  through  its  whole  extent  in  a  soft 
cushion-like  swelling,  or  in  more  localised  spongy  masses  ;  the  hyper- 
trophy does  not  extend  beyond  the  os  internum  to  the  cervix,  and  thus  re- 
sembles in  its  situation  a  decidual  membrane.  The  portions  removed  by 
the  curette  are  unusually  thick  ;  one  side  presents  a  smooth  rose-coloured 
surface  which  resembles  the  appearance  of  the  mucous  membrane  of  the 
intestine,  and  the  other  has  a  deep  red,  raw  surface.  "  The  microscopic 
examination  of  these  scrapings,"  Olshausen  says,  "  shows  that  there  is 
great  hypertrophy  of  the  mucous  membrane  with  increase  of  all  its  ele- 
ments— moderate  dilatation  of  the  lumina  of  the  glands,  eplarge- 
ment  of  the  blood-vessels,  and  marked  cellular  infiltration  of  the  con- 
nective tissue  "  (Fig.  187).  The  characteristics  of  this  type  are,  that  the 
glands  do  not  become  enlarged  so  as  to  produce  cystic  dilatations,  and 


ffiMMIli^^ 


Fig;  187. 

Vascular  type  of  cndometritis — endometritis  fungosa  (Olshausen). 

that  the  blood-vessels  are  greatly  distended :  the  latter  fact  explains  the 
hemorrhage  which  is  the  chief  symptom.  The  absence  of  the  increased 
leucorrhoeal  discharge,  so  characteristic  of  the  polypoidal  form,  is  probably 
due  to  the  fact  that  the  glands  are  not  markedly  affected.  De  Sincty 
gives  a  figure  which  shows  the  dilatation  of  the  blood-vessels  in  this  vas- 
cular type  of  endometritis  (Fig.  188). 

The  third  type  is  described  only  by  De  Sinety.  "In  other  cases,"  he 
says,  "  the  vegetations  are  specially  constituted  of  embryonic  tissue  with 
few  blood-vessels.  There  are  only  traces  of  the  glands  and  some  remains 
of  more  or  less  degenerated  epithelium.  We  have  to  do  with  a  truly  in-j 
flammatory  tissue  comparable  to  that  which  forms  upon  an  exposed 
wound.  At  certain  points  there  are  islands  of  degenerated  elements 
which  are  not  colored  by  reagents  and  are  analogous  to  those  observed  in 
foci  producing  pus.  This  degeneration  of  embryonic  elements  explains  to 


AFFECTIONS    OF   THE    UTERUS. 


303 


us  the  abundance  of  the  muco-purulent  discharge  observed  during  life  " 
(Fig.  189). 

When  chronic  endoinetritis  has  persisted  for  a  long  time,  the  mucous 
membrane  becomes  atrophied  :  the  ciliated  and  afterwards  the  cylindrical 


Cross  section  of  granulation  composed  of  dilated  vessels  in  a  case  of  endometritis  «Yi-  I,  rowels  cat 
longitudinally;  2,  vessels  cut  transversely  ;  3,  dilated  vessel  filled  with  blood-corpuscles;  4,  embryonic  tis- 
ene  (De  Sin6ty). 

epithelium  is  lost,  and  small  polymorphous  cells  resembling  squamous 
epithelium  take  their  place  ;  finally,  the  mucous  membrane  disappears 
altogether  and  the  uterine  cavity  comes  to  be  lined  with  a  layer  of  con- 
nective tissue.  The  glands  fall  out  so  that  the  mucous  membrane 


Fig;.  189. 

Cross  section  of  granulation  composed  of  embryonic  elements,  from  a  case  of  endometritis  *'/,.  1,  em- 
bryonic tissue  :  2,  part  undergoing  fatty  degeneration  (De  Sinety). 

becomes  mesh-like,   or  they  are  constricted    to    form  retention  cysts 
(Schroeder). 

Senile  atresia  of  the  cervical  canal  is  the  result  of  a  localised  chronic 
endometritis.  This  is  one  of  the  physiological  changes  which  occur  after 
the  menopause.  In  some  cases,  however,  it  becomes  pathological ;  ac- 
cumulation of  mucus,  more  rarely  of  blood,  takes  place  above  the 
obstruction  and  produces  the  changes  of  endometritis. 


304  MANUAL    OF    GYNECOLOGY. 

Routh  describes  a  form  of  endometritis  in  which,  the  inflammatory 
process  is  limited  to  the  fundus  uteri — the  area  between  the  orifices  of 
the  Fallopian  tubes  ;  his  description  is,  however,  based  on  clinical  observa- 
tion rather  than  pathological  data. 

ETIOLOGY. 

Acute  endometritis  is  a  rare  condition,  and  never  occurs  before  puberty. 
It  comes  on  most  frequently  in  connection  with  menstruation,  when  the 
physiological  congestion  readily  passes  into  inflammation.  It  is  occa- 
sioned by  exposure  to  cold  or  sexual  excess  at  the  periods,  and  by  the  ex- 
tension of  gonorrhoeal  inflammation  from  the  mucous  membrane  of  the 
vagina.  It  also  occurs  in  the  exanthemata,  typhus,  scarlet  fever,  and 
measles  ;  it  has  further  been  observed  in  cholera  (Slavjansky),  and  in 
certain  cases  of  phosphorus  poisoning.  In  puerperal  inflammation, 
endometritis  is  of  course  present. 

Chronic  endometritis  is  occasionally  the  result  of  acute  ;  most  frequently, 
however,  it  arises  independently.  Sometimes  it  is  merely  the  indication 
of  the  constitutional  state  ;  in  scrofulous  and  chlorotic  cases,  the  normal 
leucorrhcea  (which  precedes  and  follows  menstruation)  is  increased  in 
quantity  and  prolonged  during  the  intermenstrual  period.  This  is  due 
to  hypersecretion  rather  than  to  inflammation.  Increased  leucorrhcea, 
with  diminished  menstrual  flow,  is  quite  characteristic  in  phthisis. 

Chronic  endometritis  arises  independently  from  the  following  causes  : — 
Parturition,  especially  when  the  uterus  has  not  been  completely 

emptied ; 

Exposure  to  cold  during  menstruation  ; 
Obstruction  to  the  menstrual  flow  ; 

Uterine  displacements,  especially  retroflexion  and  prolapsus  ; 
Polypi  or  other  tumours  in  the  uterine  cavity ; 
Direct  injury  through  incautious  use  of  sound  or  tent ; 
Excessive  sexual  activity  ; 
Extension  of  gonorrhoeal  or  simple  inflammation  from  vagina  and 

cervix. 

Of  these  the  most  important  are  parturition  and  displacements. 
As  regards  parturition,  endometritis  is  frequent  after  abortion  ;  usually 
this  is  due  to  the  patient's  rising  too  soon,  or  to  the  incomplete  emptying 
of  the  uterus.     After  full-time  labour,  the  seat  of  the  placenta  seems  to  be 
in  many  cases  the  starting-point  of  the  inflammatory  process. 


AFFECTIONS    OF    THE    UTl-KTS.  ;j()5 

In  nulliparrc  with  a  narrow  os  externum  causing  obstruction  to  the 
menstrual  now,  we  frequently  find  the  uterine  cavity  increased  in  length 
and  endometritis  present. 

Uterine  displacements  do  not  necessarily  produce  endometritis.  We 
sometimes  find  a  retroversion  or  retrotfexion  which  has  produced  no 
symptoms.  As  a  rule  chronic  inflammation  of  the  endometrium,  as  well 
as  of  the  muscular  coat,  results  from  passive  congestion. 


SYMPTOMS. 

A.    Of  Acute  KiKlnmi'triti*. 

These  are  fever  more  or  less  severe  according  to  the  inflammation, 
pain  in  the  back  and  lower  part  of  the  abdomen  with  the  sensation  of 
weight  in  the  pelvis,  and  in  severe  eases  vesical  and  rectal  tencsmus. 
The  characteristic  symptom  is  the-  discharge,  which  is  at  first  clear  and 
watery,  but  after  a  few  days  becomes  creamy  and  purulent.  The  men- 
strual flow  is  sometimes  suppressed,  rarely  is  it  increased. 

/.'.    Of  Chrnni'-  Kt,<l<,m>-triti*. 
The  leading  symptoms  are  the  following: 

Leucorrluea  ; 
Menorrhagia  ; 
J)ysmenorrho-a  ; 
Weakness  in  tin-  back  ; 
Pain  in  pelvis  and  loins  ; 
Digestive  derangements  ; 
Xervous   derangements  : 
Sterility  ; 
Abortion. 

Leiicorrhwi  is  the  characteristic  symptom.  The  secretion  from  ti.e 
body  of  the  uterus  is  of  a  watery  character,  less  dense  and  gelatinmis  than 
that  from  the  cervix;  usually,  however,  there  is  cervical  catarrh  as  wt  11. 
The  uterine  secretion  lias  an  alkaline  reaction,  while  vaginal  leucorrlm  i 
is  acid.  Sometimes  if  is  tinged  with  blooil.  producing  an  appearance 
which  Bennet  aptly  compares  to  the  rust-colored  sputum  in  pneumonia. 

This  blood-stained    leucorrha-a  must   not    be    confounded  with   the   imn- 
YGL.  I.—  20 


306  MANUAL    OF    GYNECOLOGY. 

strual  flow.     In  some  cases  the  discharge  is  purulent,  accumulates  in  the 
uterine  cavity,  and  is  only  discharged  at  intervals. 

Menorrhagia  is  frequently  present.  In  one  class  of  cases  (see  Pathology) 
it  is  the  leading  symptom,  and  is  grave  from  the  anaemia  which  it  pro- 
duces. It  shows  itself  first  in  increased  duration  of  the  menstrual  flow, 
which  becomes  gradually  prolonged  over  the  inter-menstrual  period  till 
the  loss  of  blood  becomes  continuous.  Dysmenorrhcea  is  frequently 
present,  but  is  more  probably  due  to  complications  (e.g.,  flexions  or 
chronic  metritis)  than  to  the  condition  of  the  mucous  membrane.  Mem- 
branous dysmenorrhcea  (accompanied  with  exfoliation  of  the  mucous 
membrane  at  the  menstrual  period)  might  be  considered  here,  as  its 
pathology  is  most  nearly  allied  to  endometritis ;  from  its  peculiar 
symptoms,  however,  it  is  better  to  consider  it  in  the  chapter  on 
Dysmenorrhcea  (Section  Vm.). 

"  Weakness  in  the  back  "  is  the  common  complaint  made  by  the  patient. 
It  may  amount  to  actual  pain,  but  more  generally  it  shows  itself  as  feeble- 
ness or  weariness  which  incapacitates  the  patient  for  her  daily  work. 

Derangements  of  the  digestive  and  nervous  systems  invariably  follow 
when  the  disease  has  become  chronic.  There  is  impaired  digestion  with 
loss  of  appetite  and,  as  the  result,  general  debility.  Whether  these  are 
due  to  the  drain  of  the  system  produced  by  the  leucorrhcea  or  to  the  close 
connection  between  the  nervous  centres  for  the  sexual  organs  and  those 
for  the  digestive  apparatus,  we  do  not  know.  Derangements  of  the  ner- 
vous system  show  themselves  in  frontal  headache  and  depression  of  spirits 
amounting  sometimes  to  melancholia. 

Anosmia,  with  its  characteristic  train  of  symptoms,  is  the  leading  symp- 
tom in  the  hemorrhagic  type  (Olshausen). 

Sterility  is  frequently  present,  and  has  been  in  certain  cases  the  only 
symptom  complained  of.  The  secretion  may  destroy  spermatozoa,  may 
mechanically  prevent  them  from  passing  upwards,  or  the  villi  of  the  fer- 
tilised ovum  may  be  prevented  from  finding  an  attachment  in  the  diseased 
mucous  membrane.  Again,  the  ovum  is  attached  for  a  time  but,  from  the 
imperfect  formation  of  the  uterine  portion  of  the  placenta,  abortion  takes 
place  ;  repeated  abortion  is  characteristic  in  chronic  endometritis.  A 
vicious  circle  is  thus  produced  :  as  mentioned  under  etiology,  endometritis  . 
frequently  follows  abortion ;  abortion,  in  its  turn,  frequently  follows  en- 
dometritis. 


AFFECTIONS    OF    TIIK    UTERUS. 

* 

PHYSICAL    SKINS. 

A.    Of  Acii/r  Emlnmrtritii*. 

There  is  tenderness  on  pressure  over  the  lower  part  of  the  abdomen. 
due  to  peritonitis  which  generally  accompanies  (he  acute  form.  On  vagi- 
nal examination  the  cervix  is  found  to  bo  swollen  and  pnlVv.  the  ns  is  di- 
lated and  feels  velvety  from  eversion  of  the  mucous  membrane,  the  biman- 
ual  is  unsatisfactory  from  sensitiveness  to  pressure.  The  speculum  shows 
the  vaginal  portion  to  be  congested,  with  catarrhal  patches  round  the  os 
and  the  follicles  enlarged  and  sometimes  containing  pus.  The  leucor- 
rho'al  discharge  already  described  is  seen  coming  from  the  os  uteri.  Tin,, 
sound  should  not  be  used,  as  its  introduction  causes  pain  and  soiuetimt  s 
hemorrhage. 

//.    Of  CJn-nrur  En<l»,ncti-Hi<. 

Tenderness  on  pressure  is  not  necessarily  present,  ihou./h  we  fre 
qneiltly  find  it  as  the  result,  of  complications  -  peritonitis,  cellulitis.  ova 
ritis. 

On  vaginal  examination  the  vaginal  portion  of  the  cervix  is  normal,  or 
lias  the  characters  described  under  cervical  catarrh.  The  bim;mir:!  sho\\-j 
tlie  uterus  to  be  t'n/'ir</<'</  :  it  is  soft  and  ilabby  ;-'>  that,  its  f.  >rm  cannot 
easily  be  made  out,  or  of  a  firm  consistence  tVom  chronic  nn  triti-. 

The  sound  passes  li>'i/<>,i'/  the,  '2',-inch   knob  to  a  varving  extent,  and  on 
withdrawal  is  frequently  tinged  with  blood.     Its  introduction  may  In   dii]':- 
cult  from    irregularities  in  the  mucous  membrane,  and   is  soim-tim*  -;  pain 
ful.      In   some    cases   pain  is  complained  of  when    the    sound    touches   the 
fundiis  of  the  uterus,  which   somo   consider  characteristic  of  endometrit is. 
Koutli   has  described   a  varietv  of  the   di-easo   under   the   name  ••  Fnnd-d 
Kndomotrit  is."  in   which    this    is    prominent:   on    forcible    pressure  of    tin: 
sound  against  the  fundiis  "  absolute  agony  mav  result,  which  nnv  produce 
vomiting,  an  hvsterical  faint  or  tit.  sometimes  a  regular  epileptic  lit."    Th*- 
sound  is  most  useful  in  demonstrating  //•;•<</<//>//•</"  .-   ••''  //<••   um 
hrnni'.  and   their   recognition  is  of  great    importance:   to  detect  tins-     ti.i 
sound  is  h<  Id    light  ly  bet  ween    the    linger    ami    thumb  and    moved    - 
backwards   and   for\\"ards  over  the  mucous  membrane  :  a  /ratim/  «r  catch 
ing  sensation    is  felt  when  they  are  present.      \\  e   mu-t    imte.  Imwi  v«  r.  as 
Olshausen  points  out,  that  I  lie  spongy  irregularities  may  escape  di  ti  ction 
bv  the  sound. 


308  MANUAL    OF    GYNECOLOGY. 

In  the  speculum  we  see,  issuing  from  the  os,  the  leucorrhoeal  discharge 
with  the  characteristics  given  above ;  usually  it  is  mixed  with  that  from 
the  cervix.  The  appearances  described  under  cervical  catarrh  are  also 
frequently  present. 

DIAGNOSIS  ;   DIFFERENTIAL   DIAGNOSIS. 

The  curette  is  invaluable  in  diagnosis,  especially  when  its  use  is  fol- 
lowed by  microscopical  examination  of  the  scrapings — the  importance  of 
which  cannot  be  overrated. 

This  throws  light  on  the  etiological  question,  whether  the  endometritis 
be  due  to  incomplete  emptying  of  the  uterus  after  parturition.  In  such  a 
case,  we  find  among  the  scrapings  large  decidual  cells  or  fragments  of  the 
villi  of  the  chorion  in  a  state  of  fatty  degeneration.  It  shows  us  the  char- 
acter of  the  inflammatory  changes.  Of  these  de  Sinety  describes  three 
forms  on  which  we  based  our  description  of  three  pathological  types  of 
endometritis.  The  microscopic  appearance  of  these  (40  diameters)  is 
given  at  Figs.  186  to  189. 

It  enables  us  to  differentiate  endometritis  from  commencing  malignant 
disease — carcinoma  and  sarcoma.  In  carcinoma,  we  see  under  the  micro- 
scope abundance  of  epithelial  cells  of  irregular  form  and  with  many  nuclei 
(•u.  Chap.  XXXIX.).  In  sarcoma  we  see  under  the  microscope  the  typical 
round  or  spindle-shaped  cells.  The  hemorrhagic  type  of  endometritis 
may  readily  be  mistaken  for  sarcoma  uteri,  because  "it  spreads  in  a  diffuse 
manner,  pre-eminently  causes  hemorrhage,  produces  pain  not  at  all  or 
only  late  "  (Olshauseri).  The  microscope,  however,  settles  the  diagnosis. 
Care  must  be  taken  not  to  mistake  the  small-celled  infiltration  of  the  tis- 
sue (Fig.  187)  for  round-celled  sarcoma.  The  unstriped  muscular  fibre  of 
the  uterus  may  be  present  in  the  scrapings,  but  could  only,  on  hasty  ex- 
amination, be  mistaken  for  spindle-celled  sarcoma.  The  latter  are  charac- 
terised by  their  larger  size  and  oval  nuclei  (v.  Chap.  XLTT.). 

PROGNOSIS. 

Endometritis  is  not  a  fatal  disease  in  itself,  though,  when  long  pro- 
tracted, it  seriously  affects  the  constitution  and  produces  permanent  ill- 
health.  In  cases  of  excessive  hemorrhage,  the  condition  becomes  grave. 

The  treatment  is  often  protracted,  and  the  patient  should  always  be 
warned  of  this.  The  occurrence  of  conception  will  produce  the  most  fa- 


AFFECTIONS    OF    THE    UTERUS.  ,')(>!> 

vorable  conditions  ;  and,  if  due  care  be  taken  to  prevent  abortion  in  the 
early  months  and  in  the  management  of  the  puerperium,  we  mav  hope  for 
a  cure. 

"When  endometritis  is  associated  with  a  strumous,  tubercular,  or  syph- 
ilitic  diathesis,  it  may  bailie  all  our  efforts. 

TREATMENT. 

A.    Of  Ac  ate  Endumctrifis. 

Rest  in  bed.  warm  fomentations  over  the  abdomen,  and  the  free  use  of 
opium  if  there  is  much  pain,  form  all  the  treatment  required.  Should  the 
bowels  not  be  moved  freely  before  the  attack,  castor-oil,  with  an  enema. 
should  be  given,  since  the  loaded  rectum  presses  injuriously  on  the  in- 
flamed uterus.  Should  the  bowels  not  be  loaded,  the  patient  is  not  to  be 
troubled  with  purgatives  but  rather  kept  under  the  influence  of  opium. 
If  there  is  menorrhagia,  ergot  is  reijuired  ;  when  the  discharge  is  five,  it 
is  to  be  given  hypodermic-ally.  Warm  water  injections  should  not  be 
used  until  the  acute  .stage  is  passed,  the  pain  and  other  Mgns  of  inflamma- 
tion have  subsided,  and  the  leucorrhu-a  is  abundant. 

11.    Of  Chrome  En<1nin,-trHi.<. 

Prophylactic  treatment  is  of  great  importance'.  A  patient  \sho  is  sub- 
ject to  endometritis  should  guard  against  exposure  during  the  menstrual 
period.  "When  conception  takes  place,  the  practitioner  should  remember 
the  liability  to  abortion,  the  importance  of  seeing  that  the  uterus  be 
thoroughly  emptied  after  parturition,  and  that  the  patient  t  ike  proper 
care  during  the  puerperium  ;  in  the  latter  period  ergot  is  beneficial. 

"We  begin  with  hot  water  injections,  and  the  administration  oi  ergot  ; 
the  liquid  extract  in  doses  of  twenty  drops  in  water  fhivr  times  a  day.  in- 
creased to  thirty  at  the  menstrual  period,  is  the  most  con\vm>  m  form. 

If  the  uterine  cavit  v  be  enlarged  so  that  the  sound  moves  frei  ly  \s  n  Inn 
it,  if  there  be  roughness  of  the  endomet  riuni,  or  if  tin  iv  has  been  a  n  cei,1 
miscarriage  or  confinement.  \\e  employ  /<  ''I'!" 

tinnnf  cni'bolir   tin, I.       In    the    last    class    of    cases    the    cans,     of    the    uido 
mctritishas  been  the  incomplete  separation  of  the  pi  ic.  ntal  \ 
while  still  recent,  such  cases  furnish  the  mo.-t  satisfactory  nist- 
immediate  and  complete  cure. 

Curetting  should  not  be  performed  while  active  ctlluliti.-    >r  p   i 


310  MANUAL    OF    GYNECOLOGY. 

is  present.  The  fixing  of  the  uterus  by  adhesions  or  cicatrisation  does  not 
contra-indicate  the  operation,  though  they  render  it  more  difficult  through 
preventing  the  uterus  from  being  drawn  down  by  the  volsella  ;  when  these 
are  present,  undue  traction  must  not  be  made.  The  time  selected  for 
operation  is  a  week  after  a  menstrual  period  ;  when  the  discharge  is  con- 
tinuous, the  period  is  indicated  by  increase  in  amount. 

Curetting  of  the  Uterus  with  application  of  Carbolic  Add. — The  following 
instruments  are  necessary  : — 

Sims'  or  Battey's  speculum, 

Three  or  four  sounds  dressed  with  cotton  wool, 

Volsella, 

Simpson's  modification  of  the  dull-wire  curette, 

Crystals  of  carbolic  acid  liquefied, 

Cotton  wadding  and  glycerine, 

Mackintosh. 

Chloroform  is  not  necessary  unless  the  patient  be  nervous. 
The  sounds  should  be  covered  with  a  thin  layer  of  cotton- wool,  extend- 
ing almost  to  the  knob  (Fig.  190).     The  sound  is  dressed  as  follows :   A 


Tig'.  190. 
Sound  dressed  with  wadding  for  the  application  of  carbolic  acid. 

film  of  cotton  wadding  is  laid  on  the  palm  of  the  left  hand,  the  last  two 
and  a  half  inches  of  the  sound  are  moistened  and  pressed  firmly  on  the 
cotton  wadding,  the  left  hand  is  closed  over  it,  the  sound  is  turned  twice 
or  thrice  round  within  the  shut  hand  till  the  cotton  wadding  becomes 
tightly  rolled  on.  The  dressing  must  bite  the  sound  firmly  so  that  it  may 
not  come  off  within  the  uterine  cavity,  and  must  not  be  too  thick  to  be 
easily  carried  in.  To  remove  the  cotton  wadding  afterwards,  the  dressing 
is  unrolled  under  water. 

Thomas'  dull-wire  curette  is  the  most  serviceable,  because  from  its 
small  size  it  can  be  used  without  previous  dilatation  and  from  its  flexibil- 
ity it  can  be  curved  to  suit  the  form  of  the  uterine  canal.  A.  R.  Simpson 
has  distinctly  improved  it  by  adding  a  knob  at  the  two  and  a  half  inches, 
which  informs  the  operator  where  the  end  of  the  curette  is.  The  crystals 
of  carbolic  acid  are  kept  in  stoppered  bottles  ;  at  the  ordinary  temperature 


AFFECTIONS    OF   THE    UTERUS. 


311 


a  portion  remains  liquid ;  iodine,  strong  nitric  acid,  or  chromic  acid  may 
be  substituted  for  it. 

The  patient  is  placed  semiprone  ;  Sims'  speculum  is  passed  and  held 
by  an  assistant  who  with  the  left  hand  draws  back  the  upper  labium  (Fig. 
191)— if  there  be  no  assistant,  Battey's  speculum  is  used  and  fixed  to  the 
mattress  ;  the  vagina  is  washed  out  with  carbolised  water.  The  anterior 
lip  is  laid  hold  of  by  the  volsella  and  drawn  downwards,  the  volsella  being 
steadied  with  the  fingers  of  the  left  hand  ;  the  curette  is  taken  in  the  right 
hand,  dipped  in  carbolised  oil  (1-20),  and  carried  into  the  uterine  cavity 


Eg.  T9L 

Uterus  drawn  down  with  the  volsella  and  curette  In  position.     The  speculum  is  held  and  the  Inbium  drawn 
upwards  by  an  assistant.     The  operator's  hands  are  crossed  (A.  K.  Simpson). 

(Fig.  191).  The  anterior  wall  of  the  uterus  is  first  scraped,  from  the  fun- 
dus  downwards  ;  only  slight  pressure  on  the  instrument  is  made,  unless 
it  be  felt  to  slip  over  the  irregularities  of  the  mucous  membrane  without 
removing  them ;  the  detached  fragments  are  brought  down  to  the  cervix 
with  a  raking  motion,  and  set  aside  for  microscopical  examination  :  the 
posterior  wall  is  scraped  in  the  same  way.  A  sound,  dressed  with  dry 
cotton  wadding,  is  passed  to  clear  away  the  blood  and  mucus  ;  the  same 
process  is  immediately  repeated  with  a  second,  and  with  a  third  if  neces- 
sary. A  reserve  sound,  previously  dipped  in  the  carbolic  acid  so  as  to  be 


312  MANUAL    OF    GYNECOLOGY. 

ready  for  use,  is  carried  in  immediately  after  the  last  of  these  has  been 
withdrawn ;  if  there  is  much  bleeding  or  the  uterine  cavity  be  large,  a 
second  application  should  be  made  ;  our  aim  is  to  apply  the  carbolic  acid 
to  the  whole  of  the  raw  surface,  without  its  being  diluted  with  blood  or 
mucus.  The  volsella  being  withdrawn,  a  pledget  of  cotton  wadding 
soaked  in  glycerine  is  placed  in  the  upper  part  of  the  vagina  so  as  to  em- 
brace the  cervix ;  this  prevents  the  carbolic  acid  from  running  down  into 
the  vagina. 

The  patient  keeps  her  bed  for  a  week  after  the  operation,  the  pledget 
having  been  removed  on  the  second  day.  Special  care  should  be  taken  at 
the  next  menstrual  period. 

Applications  without  a  previous  curetting  are  indicated  in  cases  where 
there  is  no  history  of  recent  parturition  or  where  no  irregularities  are  de- 
tected by  the  sound.  (In  endometritis  fungosa,  which  specially  requires 
the  curette,  no  irregularities  are  detected  by  the  sound — Olshausen.)  In 


Fig.  193. 

Porte-canstique  (Sir  J.  Y.  Simpson). 

all  other  cases  the  preliminary  use  of  the  curette  is  a  distinct  advantage, 
as  it  removes  the  fungosities  and  thus  allows  the  caustic  to  act  more  effi- 
ciently. 

Atthill  advocates  the  use  of  strong  nitric  acid,  and  the  preliminary 
dilatation  of  the  cervix  with  tents  so  as  to  allow  a  thicker  dressing  of  the 
sounds  and  more  abundant  application  of  the  acid.  He  uses  an  intra- 
uterine  speculum  of  vulcanite  which  is  passed  within  the  cervix  ;  this  pre- 
vents the  acid  from  acting  on  the  cervical  canal. 

The  application  may  be  made  in  a  solid  form,  of  which  the  best  is 
nitrate  of  silver.  This  is  employed  as  follows  :  the  nitrate  of  silver  is  fused 
in  a  water  glass  over  a  spirit  flame  ;  a  probe  with  a  roughened  end  is 
dipped  in  this  and  the  film  allowed  to  cool,  and  then  dipped  again  repeat- 
edly till  several  layers  are  deposited.  Sir  James  Simpson  applied  the 
nitrate  of  silver  in  powder  on  the  porte-caustique  represented  at  Fig.  192. 
The  simplest  way  is  to  carry  an  ordinary  quill  with  a  nitrate  of  silver  point 
into  the  cavity  of  the  uterus  ;  it  may  be  passed  in  and  withdrawn  again, 
or  held  there  till  the  point  melts  off;  Crede  of  Leipsic  has  got  very  good 


AFFECTIONS  OF  THE  UTERUS.  313 

results  from  this  mode  of  treatment.  Barnes  has  devised  an  ointment 
positor  for  introducing  ointments  or  fluids  ;  he  applies  the  iodide  of  mer- 
cury ointment  in  this  way,  and  also  tincture  of  iodine  on  a  sponge. 

The  importance  of  constitutional  treatment  must  not  be  forgotten.  The 
bowels  should  be  moved  regularly  by  saline  aperients ;  the  aloes  and  iron 
pill  is  also  useful.  The  preparations  of  quinine,  iron,  and  strychnine,  are 
valuable  in  improving  the  tone  of  the  nervous  and  digestive  systems. 

Cold  baths  and  sea-bathing  aid  greatly  in  strengthening  the  constitu- 
tion. The  water  of  certain  mineral  springs,  such  as  Ems  and  Kreuznach, 
seems  to  have  a  special  action  on  the  uterine  as  well  as  on  other  mucous 
membranes.  The  regular  diet  and  exercise  required  at  these  baths  have 
also,  no  doubt,  their  beneficial  effect. 

The  diathesis — strumous,  tubercular,  or  syphilitic — should  not  be  for- 
gotten. In  them,  the  treatment  must  from  the  first  be  constitutional. 

Intra-uterine  Injections. — Applications  to  the  interior  of  the  uterus  are 
also  made  in  the  form  of  a  fluid  injected  by  a  syringe.  The  nozzle  of  the 
latter  is  shaped  like  a  sound,  so  that  it  may  be  passed  into  the  uterine  cavity  ; 
the  barrel  is  of  glass,  and  is  graduated  (like  a  hypodermic  syringe)  so  that 
the  quantity  injected  (not  more  than  a  few  minims)  is  exactly  known.  The 
solutions  used  are  carbolic  or  chromic  acid,  tincture  of  iodine  or  per- 
chloride  of  iron,  nitrate  of  silver,  and  sulphate  of  iron  or  copper.  The 
cervix  must  be  well  dilated,  to  allow  the  fluid  to  escape  readily  past  the 
nozzle  of  the  syringe.  To  facilitate  this  reflux,  syringes  have  been  devised 
with  a  double  canula.  Injection  of  fluid  into  the  non-puerperal  uterus  is 
not  unattended  with  risk  (u.  p.  188),  and  the  fact  that  we  have  the  equally 
effective  and  perfectly  safe  method  of  intra-uterine  medication  described 
above  renders  it  unnecessary.  As  a  means  of  treating  endometritis  it  is 
condemned  by  the  general  opinion  of  gynecologists  in  this  country  and 
America  ;  in  France  and  Germany,  however,  it  is  extensively  practised. 
For  further  details  of  this  method  the  student  may  consult  the  following 
references  :  Klemm — "  Die  Gefahren  der  Uteriuinjection,"  Leipzig,  1863  ; 
Cohnstein — "Beitrage  zur  Therapie  der  chronischen  Metritis,"  Berlin, 
1868  ;  Leblond  — op.  cit.  ;  and  Hegar  und  Kaltenbach — op.  cit.,  S.  104. 


END   OF  VOLUME  I. 


Date  Due 


CAT.    NO     ?3    233  PRINTED    IN    U.S.A. 


WP100 


1883 
v.l 

Hart,  David  Berry. 
Manual  of  gynecolocy 


WP100 
H325m 
1883 

Hart,  David  Berry 

Manual  of  gyneiology. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


